EMPLOYMENT HISTORY AND SOCIAL AND COMMUNITY ACTIVITY FOR RETIRED NFL FOOTBALL PLAYERS The Qualified MAF Physician will ask you about what work and business activity you do, and about the social, volunteer and recreational things you do outside your home. You can fill out this form and take it with you to the exam. I. RETIRED NFL FOOTBALL PLAYER First M.I. Last Retired Player Name Retired Player Date of Birth / / (Month/Day/Year) II. EMPLOYMENT AND BUSINESS ACTIVITIES Describe your employment and business activities over the five years before the exam, including anything in which you were or are self-employed, such as in a consulting role or making compensated appearances. Attach more pages if you run out of space. Employer or Business Position Dates of this Work From To Street 1. Address City State Zip Code Duties Reason for Leaving 546192 www.NFLConcussionSettlement.com Page 1 of 4 Phone Employer or Business Position Dates of this Work From To Street 2. Address City State Zip Code Phone Duties Reason for Leaving Employer or Business Position Dates of this Work From To Street 3. Address City State Zip Code Phone Duties Reason for Leaving Employer or Business Position Dates of this Work From To Street 4. Address City State Zip Code Duties Reason for Leaving 546192 www.NFLConcussionSettlement.com Page 2 of 4 Phone III. SOCIAL AND COMMUNITY ACTIVITIES Describe any of these things you do outside your home now and how that has changed over the last five years, if it has. Include activities you used to do but have stopped and the reason for stopping. Attach more if you need more space. Activity Description ☐ Participating in Social Functions, Clubs, Sporting Events, Church or Other Group Activities ☐ Visiting with Friends or Family ☐ Public Speaking ☐ Driving 546192 www.NFLConcussionSettlement.com Page 3 of 4 ☐ Operating Heavy Machinery or Boats ☐ Coaching (volunteer) ☐ Volunteering in Service Organizations and Charities ☐ Other ☐ Other IV. SIGNATURE Signature by Retired NFL Football Player or Representative Claimant Date / / (Month/Day/Year) First M.I. Printed Name 546192 www.NFLConcussionSettlement.com Page 4 of 4 Last