Tennessee Tech NIL Activity Pre-Approval Form

For: Student-Athletes who will be or have been compensated for the use of their names, images, and likenesses for promotional purposes.

Action: Complete the form in its entirety and sign and return to Amanda Thatcher, Assistant AD for Compliance. This information will be kept on file in a manner consistent with federal and state law, if applicable.

Due Date: Prior to participation in NLI activities. Failure to disclose may impact the student-athletes' eligibility.

Email address *

First name *

Last name *

Cell Phone Number *

Sport(s) *

T-Number *

Is this a one-time activity? *

If yes:

Please list start date of activity and the end date of the activity

If no, how many activities will you be involved in for this one company (provide number or estimated number, i.e. 15 posts):

Please list the number of activities, initial start date of activities and estimated end date of activities

Provide estimated start and end dates for each activity:

If there is start or no end date to the activity, please explain (i.e. posting monthly for the next year ? provide first posting date and/or all anticipated dates the student ? athlete will be posting):

How will you be compensated for your Name, Image and Likeness Activity(s)? *

Method of Payment (Check all that apply):

Cash Check Direct Deposit Tips Other

If Other, please explain briefly - i.e. Venmo, PayPal, merchandise, etc.):

Complete one of the following payment choices:

Pay Rate ($/hour)

$/Per Post

$/Lump Sum

$Total Compensation

Other:

Explain (i.e. Athlete kept all clothing used during photoshoot, received merchandise or discount)

How will you travel to the Name, Image and Likeness Activity, if applicable? *

Self Parent Friend Company Public Transit Other

If Other, please explain (i.e. no transportation needed):

What is your schedule? *

Anticipated days of the week the student-athlete will be involved in activities (check each day you will be or likely will be taking part in activities)

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Name of company compensating you for NIL *

Company's Phone # *

Company's Street Address *

City, State, Zip Code *

Contact Person *

Contact Person's Cell Phone # & Email Address *

Brief description of the activity you will be participating in (i.e. Need to post on social media Sunday ? Friday any time of day): *

Brief description surrounding what are/were the terms of the agreement or transaction: *

List all parties to the agreement or transaction, other individuals and entities, and or professional service providers. If no others were involved in this transaction, please put N/A: *

Please list the name of each person/entity, their role and their contact information (including cell and/or email)

Were you referred by anyone for this activity? *

If yes, who referred you:

Date of submission *

Date Picker

Age *

Date of Birth *

Date Picker

By submitting this form, I acknowledge that my institution, or a designee of my institution, may review the accuracy of this information, and I consent to any investigation, review, or audit. I acknowledge that inaccurate or incomplete disclosure or failure to cooperate could support a reasonable conclusion that compensation I received constituted an inducement to attend or remain enrolled at a specific school, a substitute for pay for athletics performance or participation, or an otherwise illegitimate source of compensation for use of my name, image, and likeness.

* required field