Name, Image & Likeness Disclosure Form

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Email address *

Name

Sport

Phone

Description of NIL Activity

Name of Company/Person that NIL deal is with* *

What are the terms of the agreement? *

Date activity will begin *

Date activity will end

Did you use, or plan on using, an agent or legal representation?* *

Yes No

How will you be compensated? *

If you will be compensated with money, please the list the amount: *

Will any college facilities be used for this activity?* *

Yes No

Will the Bergen logo be used? *

Yes No

Signature of Student-Athlete *

Date *

* required field