Name, Image and Likeness (NIL) Disclosure Form - Suffolk

Email address *

Name: *

Student ID Number: *

Sport: *

Contact Number: *

Please review the Suffolk University Name, Image and likeness policy for the University's applicable requirements associated with earning compensation for your name, image and likeness (NIL).

To review, please follow this link: Suffolk University Name, Imange and Linkess (NIL) Policy

For a list of definitions, please follow this link: NIL Definitions

Student-athletes must disclose the NIL contract whether written or verbal to the institution at least seven (7) days prior to entering into the contract.

Proposed Start Date of Activities *

Date Picker

Proposed End Date of Activities *

Date Picker

A student-athlete may hire professional representation (e.g. an agent, attorney, tax advisor, marketing consultant, or brand manager) for advice, contract representation and the marketing of their NIL, so long as the professional representation is NOT representing the student-athlete in securing professional athletic opportunities or financial gain and as a professional athlete.

Will you be obtaining professional representation for your NIL? *

Yes No

If Yes, please provide the following contact information for this representative.

Name, Phone, Email, Address

NIL Activity Information:

Describe the name, image and likeness activity: *

What are the terms of the proposed contract or transaction? *

If you have a written contract, please forward a copy to Adam Skaggs, Associate Director of Athletes (adam.skaggs@suffolk.edu)

How will you be compensated for participating the in the name, image and likeness activity? *

Suffolk University strongly recommends all NIL agreements be in writing and kept in a safe space in case it needs to be referenced at a later time.

List all parties to the agreement or transaction, other individuals and entities, and professional service providers. (Name, Role, Contact Info) *

Affirmations

I have read and accept Suffolk University's Name, Image and Likeness (NIL) Policy *

Initial

I acknowledge that Suffolk University, or a designee, may review the accuracy of this information, and I consent to any investigation, review, or audit *

Initial

Compensation is related to actual use of my name, image and likeness and is not contingent on enrollment at a particular institution or a substitute for pay-for-athletics performance. *

Initial

Signature of Student-Athlete *

Date *

Date Picker

Date of Birth *

Date Picker

Parent/Legal Guardian Signature

(if student-athlete is a minor)

Date:

Date Picker

* required field