Free Multi '08.pmd - Indiana


File Size: 68.8 kB
Pages: 2
Date: June 19, 2009
File Format: PDF
State: Indiana
Category: Government
Author: dpitman
Word Count: 1,191 Words, 7,474 Characters
Page Size: 612 x 1008 pts
URL

http://www.state.in.us/icpr/webfile/formsdiv/46652.pdf

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OFFICE USE ONLY
License Year:

INDIANA HORSE RACING COMMISSION
Multi-Purpose License Application
State Form 46652 (R17 / 5-09) Approved by State Board of Accounts, 2008

New Date Total Fees Cash Clerk Reviewed by:

or

Renewal

/

/

Check

M.O. F.P.

(Not for use by Owners, Multiple Owners or Vendor Contractors)

$15 Fee
Exercise Rider Groom -Breed(s): Pari-Mutuel Clerk Pony Rider Track Employee List Occupation Above Track Security Vendor Employee List Company Name Other
List type

$35 Fee
Jockey Apprentice Jockey Starting Gate Crew Assistant Trainer -Breed(s): Authorized Agent Driver Farrier Farrier'sAssistant Indicate Employer Racing Official Type Official Trainer -Breed(s): Veterinarian's Helper DVM's Name Valet

$60 Fee
Driver/Trainer Track Management

First Name

$100 Fee
Practicing or Track Vet
(Circle which Type Vet)

Massage Therapist - Breed(s): Equine Dentist -Breed(s): Jockey Agent No Fee Commissioners/IHRC Staff

Fingerprints may be needed. Fingerprint fee is determined based upon residency. Call for fee structure.

1. Have you been previously licensed by the Indiana Horse Racing Commission (IHRC)?
If yes, please list your IHRC license number here: #

Yes

No

2. Name of applicant
Last Name

Last

First

Middle

Maiden

3. Have you ever used an assumed name or been known by another name? If yes, give name(s)/nickname(s) 4. Are you married? Yes No If yes, give full name of spouse, including maiden name: 5. Telephone numbers: ( )
Home

Yes

No

OFFICE USE ONLY

(

)
Cell/Business

(

)
Fax

6. Person to be notified in case of emergency: 7. Security Number Sex Height Weight Color Hair

Telephone: ( Color Eyes

) Age*

Birth Date

Social Security Number is being requested to pursue statutory responsibilities and is voluntary.

8. Are you a U.S. Citizen?

Yes

No

If no, of what country are you a citizen?

Immigration registration number (if applicable) A9. Permanent address:
Street City State/Province Zip

10. Local address:
City 11. USTA Number

(Need only complete this question if Permanent Address differs from Local)

(

)

State/Province USTA Exp. Date

Zip Trainer Designation: Driver Designation: G A

Local Phone # L P CD QF CD

(USTA question above pertains to Standardbred licensees only. Please circle designation to the right.)

12. Give the following information relative to your current employer. If self-employed, so indicate:
Date Employed Name of Employer Address (Street, City, State, Zip)

13. Yes No

Have you been previously licensed by another racing jurisdiction? If yes, give the following information on current and most recent license(s):
Date Type (occupation) State/Province/Country License Number

(a) (b)
Continued On Reverse Side

14.

Yes No

If married, has your spouse been previously licensed by another racing jurisdiction? If yes, give the following information on his/her current and most recent license(s):
Date Type (occupation) State/Province/Country License Number

(a) (b) 15. a) Yes No b) Yes No c) Yes No Yes d) No e) Yes No Have you ever been SUSPENDED for more than five (5) days? Have you ever been FINED over $100? Has your racing license (or your spouse's) ever been DENIED or REVOKED? Do you (or your spouse) have PENDING racing violations? Have you or your spouse ever been RULED OFF or BARRED from a race track? If any question in 15 a, b, c, d or e was answered as YES, you must provide the following:
Date (1) (2) State Track Specific Violation Penalty

16. a) Yes No b) Yes No c) Yes No (1) (2) (3)

Have you (or your spouse) ever been ARRESTED? You must answer YES, even if charges were dropped or dismissed. Are you (or your spouse) currently on PAROLE or PROBATION? Are there CRIMINAL charges currently pending against you (or your spouse)? If any question in 16 a, b or c was answered as YES, you must provide the following:
Date of Arrest State Arresting Agency Offense Outcome/Sentence

If you need more space to report additional information related to any of the questions above, please attach a separate page.
17. IHRC Rules Require Worker's Compensation Act Compliance. Licensed employers shall carry worker's compensation insurance covering their emplolyees as required by 71 IAC 5-1-10.

Indiana Horse Racing Commission Affidavit
I understand that participation in racing in Indiana is a privilege, not a right, that the license issued pursuant to this Application is subject to conditions precedent as set out in the applicable Indiana Rules and Regulations, and that my failure to comply therewith, including but not limited to misstatements or omissions in the foregoing application, shall be grounds for immediate revocation or suspension of such license. By acceptance of said license, I agree to abide by the statutes of the State of Indiana relating to racing, the applicable Indiana Rules and Regulations and rulings or decisions of the Judges/Stewards with the knowledge that rulings or decisions of the Judges/Stewards shall remain in force until reversed or modified by the Indiana Horse Racing Commission. I hereby acknowledge that I will be subject to the searches, either in my presence or absence, provided for in Indiana Code 4-31-13, as amended, and the Indiana Rules and Regulations that authorize personal inspections, inspection of any personal property, and inspections of premises and property related to my participation in a race meeting by persons authorized by the Indiana Horse Racing Commission. I also acknowledge that I may be requested to provide a breath or urine sample in accordance with Indiana Code 4-31-8, as amended, and the applicable Indiana Rules and Regulations. I further acknowledge that the Indiana Horse Racing Commission may seize any article or substance which is found in my possession or control or in a location under my control which may be forbidden or is against the applicable Indiana Rules and Regulations. I hereby waive all claims and remedies with the exception of those provided for by the Indiana Administrative Orders and Procedure Act (contained at Indiana Code 4-21.5-1, et seq.), and the applicable Indiana Horse Racing Commission Rules arising therefrom against the Indiana Horse Racing Commission and its members, employees and agents and the racing association on whose premises the search and/or seizure is made and the officials, employees and agents of such association. I hereby certify that I have read the foregoing Application and affirm that every statement contained therein is true and correctly and completely set forth. I do hereby authorize the Indiana Horse Racing Commission, the Indiana State Police, and the Federal Bureau of Investigations to investigate and verify all information contained in this Application. / /

Signature of Applicant *

E-mail Address

Date

* If applicant is under 16 years of age, and working for a licensed Parent or Legal Guardian, this Application must be signed by applicant's
Parent or Legal Guardian in the presence of one or more track judge or steward. Parent or Legal Guardian hereby provides permission of licensure and accepts responsibility of such licensure.

Signature of Parent or Legal Guardian

/ / Date

Acknowledgment by Judge or Steward

To be completed by Applicant's Employer:

Signature Of Employer
c/o Hoosier Park, 4500 Dan Patch Circle Anderson, IN 46013 P: 765-609-4855 F: 765-683-2565

Company Name

IHRC License No.

Phone No.

~OR~

c/o Indiana Downs, 4425 N 200 W Shelbyville, IN 46176 P: 317-713-3350 F: 317-713-3355