IRTP - authorised representativedeclaration form
Please complete one declaration form per authorized representative in capital letters or type. All sections are mandatory.
Note- This form is only for completion by individual representatives of players who are to be authorized to submit personal information on behalf of a player.
Player’s Details
Family name(s) : / First name(s) :Street address :
City : / Region:
Country : / Postal Code/Zip:
Home Phone : + / Mobile : +
E-mail : / National Cricket Federation :
(Please ensure that all phone numbers include full Country and Area dialing codes.)
Authorised Representative’s Details
Family name(s) : / First name(s) :Street address :
City : / Region:
Country : / Postal Code/Zip:
Home Phone : + / Business Phone : +
Mobile : + / E-mail :
Relationship to player(e.g. agent/manager/friend/relative):
(Please ensure that all phone numbers include full Country and Area dialing codes.)
Player’s declaration
I, ______, authorise the above-named representative to provide and/or update the International Cricket Council (“ICC”) with my personal details (including demographic and contact details) and my personal ‘whereabouts’ information, through the on-line ADAMS system or manually.
I acknowledge that my authorisation does not in any way reduce or abrogate my personal responsibility as a player selected in the ICC’s International Registered Testing Pool (“IRTP”) to ensure that the personal ‘whereabouts’ information provided to the ICC is, at all times, current, accurate and complete.
I acknowledge and agree that if my authorised representative fails to provide the required ‘whereabouts’ information (whether in whole or in part) in accordance with any applicable deadline set by the ICC, or provides incorrect ‘whereabouts’ information to the ICC, then the ICC may still declare that I have either: (a) failed to advise the ICC of my ‘whereabouts’ location (a “Filing Failure” for the purposes of the ICC Code); and/or (b) failed to be available for sample collection at the declared ‘whereabouts’ location (a “Missed Test” for the purposes of the ICC Code). I further understand that such failures may give rise to the imposition of consequences upon me where it is demonstrated that an anti-doping rule violation pursuant to Article 2.4 of the ICC Code has been committed and that it shall not be a defence to any charge that I had delegated authority for such filing to the above-named representative.
Print Name: Signature:
Date (dd/mm/yy):
Representative’s declaration
I, ______, acknowledge and agree that I have been authorised to carry out responsibilities in relation to the filing of ‘whereabouts information’ of the above-named player, who has been selected in the IRTP. I acknowledge and agree that my authorisation to act in such a manner does not in any way reduce or abrogate the player’s personal responsibility to ensure that the personal‘whereabouts’ information provided to the ICC is, at all times, current, accurate and complete.
Print Name: Signature:
Date (dd/mm/yy):
Further Information & Return Details
For further information in relation to the additional obligations imposed on players selected in the IRTP, please go to the anti-doping section of the ICC’s website ( Alternatively, you can contact ICC Anti-Doping on the following contacts:
Phone: +971 4 382 8800
Mobile: +971 50 5545891 (after hours)
Fax: +971 800 42223 (confidential)
E-mail – (confidential)
Once completed, please sign and return this form by fax or e-mail to:
ICC Anti-Doping
Fax: +971 800 42223 (confidential)
E-mail: (confidential)
NOTE: Where more than one person is authorised to provide the information described above, a separate declaration form must be completed for each of theplayer’s authorised representatives.
IRTP-Authorised representative declaration form-July 2011
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