姓名
name

性别
gender

照

片

国籍
nationality

护照
passport

号码
Number

常住
Resident

地址
address

固定电话
Landline

手机
cell phone

E-mail

传真
fax

FIBA经纪人证件发证日期
The date on which the FIBA broker certificate was issued

证书有效期
Certificate expiration date

FIBA经纪人证件编号
FIBA Broker ID Number

出生年月日
Date of birth

从事篮球经纪工作累计年限
Accumulated years of experience in basketball brokerage

执业性质
Nature of Practice

专职□
Full-time □

兼职□
Part-time □

代理球员/国籍
Acting Player/Nationality

英文名：
English Name:

中文名：
Chinese Name:

国籍：
Nationality:

性别：
Gender:

去向俱乐部：
To go to the club:

※授权中国篮球协会经纪人（适用FIBA经纪人不能亲自办理备案和经纪活动情况）
※Authorized agent of the Chinese Basketball Association (applicable FIBA agent cannot handle the filing and brokerage activities in person)

姓名
name

性别
gender

籍贯
Origin

身份证号码
Identification number

年龄
age

常住地址
Usual residential address

联系
contact

方式
manner

固定电话
Landline

手机
cell phone

E-mail

传真
fax

取得中国篮球协会经纪人证书时间
Time to obtain the agent certificate of the Chinese Basketball Association

证件编号
Document number

授权内容
Licensed Content

备案
Record

经纪活动委托人
Principal of brokerage activities

FIBA经纪人个人承诺
FIBA Broker Personal Commitment

本人已了解《中国篮球协会经纪活动管理办法（试行）》和相关法律、法规的有关规定并承诺将遵照执行。
I have understood the relevant provisions of the "Measures for the Administration of Brokerage Activities of the Chinese Basketball Association (Trial)" and relevant laws and regulations, and I promise to comply with them.

本人在此特别声明，本人不存在《中国篮球协会经纪活动管理办法（试行）》禁止的情况。
I hereby declare that I do not have any circumstances prohibited by the "Measures for the Administration of Brokerage Activities of the Chinese Basketball Association (Trial)".

本人已经按照《中国篮球协会经纪活动管理办法（试行）》规定的要求向中国篮球协会提交真实、有效和完整之文件。
I have submitted true, valid and complete documents to the Chinese Basketball Association in accordance with the requirements stipulated in the Administrative Measures for Brokerage Activities of the Chinese Basketball Association (Trial).

如有违反或不符合《中国篮球协会经纪活动管理办法（试行）》的行为，本人愿意承担相关责任。
If there is any violation or non-compliance with the "Chinese Basketball Association Brokerage Activities Management Measures (Trial)", I am willing to bear the relevant responsibility.

本人签字：
Signature:

年  月  日
YYYYYYYYYYYYYYYYY

备案审定
Filing and approval

机构意见
Institutional Opinions

（盖章）
(stamped)

年   月  日
  YYYYYYYYYYYYYYYYY 

注：1.以上所列选项必须如实完整打印填写，确认无误后加贴照片并签名。
Note: 1The options listed above must be printed and filled in truthfully and completely, and the photo must be affixed and signed after confirmation.

2.请提交A4版护照复印件2张，1寸近期同版彩照2张；
2.Please submit 2 copies of A4 passport and 2 recent 1-inch color photos of the same page;

3.请提交FIBA经纪人证件复印件一份。
3.Please submit a copy of your FIBA broker ID.

4.本表可从中国篮协官方网站下载。
4.This form can be downloaded from the official website of the Chinese Basketball Association.