Free Multi-Jurisdictional License Application - Maryland


File Size: 117.2 kB
Pages: 2
Date: May 24, 2001
File Format: PDF
State: Maryland
Category: Employment
Author: Leda Dimperio
Word Count: 1,191 Words, 7,633 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dllr.state.md.us/forms/racingmultijurisapp.pdf

Download Multi-Jurisdictional License Application ( 117.2 kB)


Preview Multi-Jurisdictional License Application
Multi-Jurisdictional License Application
FOR COMMISSION USE ONLY
License No. Issued By Reviewed by Issue Date Original Renewa Fee FBI Fingerprint Date FBI Fingerprint State

TYPE OR PRINT ANSWERS TO ALL OF THE FOLLOWING QUESTIONS.
Select Breed Category Flat ___Greyhound ___ Harness____ Select License Category Owner ___ Trainer ___ Partnership ___ List Jurisdiction Asst Trainer ___ Jockey/Driver ___ Stable/Kennel ___ Kennel Owner ___ Corporation ___ Other ___
Date of Birth

Other ___ USTA/CTA Membership #__________
*SSN #, Federal ID #, or Social Insurance #

Multiple Owner ___

Color Registration ___
Maiden or Alias

Full Legal Name (First, Middle, Last)

Permanent Home Address at which service of all papers may be made upon you.

City

State

County

Zip

Home Telephone

Business/Emergency Telephone

Place of Birth

Present Address (if different from above)

City

State

Zip

Local Phone

Height

Weight

Hair Color

Sex

Marital Status

Citizenship of

Immigration ID #

Has anything changed since you were last licensed? Yes___ No___ If "yes," continue, if no, go to back of application and sign. If Applicant is married, please furnish the following information concerning your spouse:
Full Legal Name ( first, middle, last, maiden) Date of Birth

All of the following questions must be answered "yes" or "no". Give details in space provided below or on separate sheet.
1. Have you (or spouse) ever been fined over $100 or has your (or spouse) license ever been denied, suspended or revoked or is a complaint pending against you (or spouse) in any jurisdiction? 2.Have you (or spouse) ever been arrested for any crime (except minor traffic violation)? 3.Have you (or spouse) been convicted of any crime (except minor traffic violations)? 4.Are you (or spouse) presently on parole or probation for any crime? 5.Have you had your fingerprints submitted to the FBI? Year submitted________________ State submitted______________ 6.Have you ever been licensed in any other jurisdiction? If yes, list jurisdiction and capacity in which you were licensed.
Yes Yes Yes Yes Yes Yes No No No No No No

Trainers Name Employer's name at racetrack if applicable

Kennel Owner Employer's signature

List horses or greyhounds owned or leased by you, wholly or in part. A copy of the lease agreement(s) must be attached to the application.
Horse or Greyhound Name(s) Name/Address of lessor if appropriate

* Voluntary provision of Social Security Numbers is requested and will be used as a secondary identifier for credit background and other such investigations. Copyright North Amercian Pari-Mutuel Regulators Association, 1998.

Complete the following if applicable. How is ownership to be listed on official race program? Name of person designated to act for the entity in all racing matters. If in co-ownership list name and % of ownership held by each. % Share Name Name Name Name If incorporated, copy of Certificate of Incorporation must be attached. Entity fees may apply and additional forms may be required by some jurisdictions. COLORS REGISTRATION (if required) Additional Jacket Color Collar Color Cap Color COMPLETE THE FOLLOWING WORKERS COMPENSATION INSURANCE INFORMATION Workers Compensation Insurance Company Policy Number Expiration Date Name of Policy Holder Jacket Color Sleeves Color
ALL APPLICANTS MUST READ THE FOLLOWING AND SIGN BELOW

In making this application for a license to participate in racing, it is understood that an investigative report may be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics,which may be applicable. You have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By submitting this application I, the undersigned, do hereby (i) agree to abide by the rules and regulations of the pari-mutuel regulatory agency, the laws of the United States of America, Canada, state/provincial government, municipalities and other subdivisions thereof; and (ii) agree to abide by any provision regarding search and seizure which may be contained in any of the above-mentioned laws, rules and regulations, and I consent and waive any right I have to object to the search, within the grounds of a racetrack or racing association, of any premises or vehicle which I may occupy or control or have the right to occupy or control and of my person, property and effects and in the seizure of any article the having of which may be forbidden. I understand that participation in racing is a privilege, not a right, that any license issued pursuant to this form is subject to condition precedent as set out in the Rules of Racing, and that my failure to comply therewith shall be grounds for immediate voidance or revocation of such license. By acceptance of said license, I agree to abide by the Rules of Racing and rulings or decisions of the Stewards and Judges with the knowledge that rulings or decisions of the Stewards and Judges shall remain in force until reversed or modified only by the authorized regulatory agency. I hereby certify, under penalty of perjury, that I have read the foregoing form and affirm that every statement contained therein is true and correctly set forth. I do hereby agree that my license may be revoked at any time for misstatement or omissions in the foregoing form. I also agree to abide by and obey the rules and regulations and conditions of the authorized regulatory agency in the jurisdictions in which I am granted a license. I expressly agree to be subject to the subpoena powers of the authorized regulatory agency or a written request issued in lieu of a subpoena and to provide the agency with any and all such information or documents which it may so request. This agreement shall extend to anything which relates to any matter which is the subject of an agency hearing or investigation.
New York Applicants Only

New York Applicants: The authority to request personal information from you, including identifying numbers such as Federal social security and Federal employer identification numbers, and the authority to maintain such information is found in Section 5 of the New York Tax Law. Disclosure of this information by you is mandatory. The principal purpose for which the information is collected is to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns or who may have understated their tax liabilities and to generally identify persons affected by the taxes administered by the Commissioner of Taxation and Finance. The information will be used for identification and licensing purposes and for any other purpose authorized by the New York State Racing and Wagering Board which may include use in a multi-state licensing database. An investigative consumer report may be requested in connection with this application. Your signature authorizes the Racing and Wagering Board to obtain such a report, you may ask in writing whether or not a report was requested and the name and address of the consumer reporting agency used.
NOTE: Some jurisdictions may require a supplemental form to be made along with this application.

APPLICANT Signature/Date

STEWARD/JUDGE or REGULATORY AGENCY REP

© Copyright North American Pari-Mutuel Regulators Association, 1998.