NIL Disclosure Form
Submit to school compliance office before executing any NIL deal
A. ATHLETE INFORMATION
Section titled “A. ATHLETE INFORMATION”| Field | Detail |
|---|---|
| Athlete Name | $AthleteName$ |
| Student ID | $StudentID$ |
| University/School | $University$ |
| Sport | $Sport$ |
| Position | $Position$ |
| Class Year | $ClassYear$ |
| Scholarship Status | $ScholarshipStatus$ (Full / Partial / Walk-on) |
| Phone | $AthletePhone$ |
| $AthleteEmail$ |
B. DEAL INFORMATION
Section titled “B. DEAL INFORMATION”| Field | Detail |
|---|---|
| Brand/Company Name | $BrandName$ |
| Brand Industry | $BrandIndustry$ |
| Brand Website | $BrandWebsite$ |
| Deal Start Date | $StartDate$ |
| Deal End Date | $EndDate$ |
| Total Compensation | $TotalCompensation$ |
Description of NIL Activity: $ActivityDescription$
C. DELIVERABLES (Check all that apply)
Section titled “C. DELIVERABLES (Check all that apply)”- Social media post(s) — Platform: $Platform$ — Quantity: $PostQty$
- Autograph session — Date: $AutoDate$ — Location: $AutoLocation$
- Public appearance — Date: $AppDate$ — Location: $AppLocation$
- Camp/clinic participation — Date: $CampDate$
- Media interview — Outlet: $MediaOutlet$
- Digital content creation (video, photo, podcast)
- Merchandise promotion or sales
- Licensing (use of name/image on products)
- Other: $OtherDeliverable$
D. COMPENSATION STRUCTURE
Section titled “D. COMPENSATION STRUCTURE”| Type | Amount |
|---|---|
| Flat Fee | $FlatFee$ |
| Per-Post Rate | $PerPostRate$ |
| Hourly Rate | $HourlyRate$ |
| Appearance Fee | $AppearanceFee$ |
| Merchandise Royalty | $RoyaltyPercent$% |
| Product/In-Kind Value | $ProductValue$ |
| Other | $OtherComp$ |
| Total | $TotalCompensation$ |
Payment Schedule: $PaymentSchedule$ Payment Method: $PaymentMethod$ (Direct Deposit / Check / Other)
E. AGENT/REPRESENTATIVE INFORMATION
Section titled “E. AGENT/REPRESENTATIVE INFORMATION”| Field | Detail |
|---|---|
| Agency | Echelon Media Sports LLC d/b/a N.I.L.E.M.S. |
| Agent | Roechard D. Lewis |
| Ohio Agent Registration # | $RegistrationNumber$ |
| Phone | $AgencyPhone$ |
| $AgencyEmail$ | |
| Commission Rate | $CommissionRate$% |
F. COMPLIANCE CHECKLIST
Section titled “F. COMPLIANCE CHECKLIST”The undersigned confirms:
- This deal does NOT constitute pay-for-play or recruiting inducement
- This deal does NOT conflict with existing agreements
- This deal does NOT use university trademarks, logos, or facilities without written permission
- The brand is NOT in a prohibited category under institutional policy
- Compensation represents fair market value for the NIL services described
- The athlete is in good academic and athletic standing
- Ohio R.C. 4771 and UAAA requirements have been satisfied
- NCAA rules have been reviewed and this deal complies
G. ATHLETE CERTIFICATION
Section titled “G. ATHLETE CERTIFICATION”I certify that the information provided above is true and accurate. I understand that failure to disclose NIL activities may affect my eligibility.
Athlete Signature: ____________________________ Printed Name: $AthleteName$ Date: ____________________________
H. AGENT CERTIFICATION
Section titled “H. AGENT CERTIFICATION”I certify that this deal complies with all applicable Ohio law, NCAA rules, and institutional policies.
Agent Signature: ____________________________ Printed Name: Roechard D. Lewis Date: ____________________________
I. SCHOOL COMPLIANCE OFFICE
Section titled “I. SCHOOL COMPLIANCE OFFICE”| Decision | |
|---|---|
| [ ] Approved | |
| [ ] Denied | |
| [ ] More Information Needed |
Notes:
Compliance Officer Signature: ____________________________ Printed Name: ____________________________ Title: ____________________________ Date: ____________________________
This form must be filed within the timeframe required by your institution’s NIL policy. NCAA rules require deals over $600 to be reported via NIL Go within 5 business days.