Free Vendor App'08.pmd - Indiana

OFFICE USE ONLY

INDIANA HORSE RACING COMMISSION
Vendor/Contractor License Application
State Form 46697 (R15 / 5-09) Approved by State Board of Accounts, 2008

License Year
New Date Total Fees Cash Clerk Check M.O. F.P. or Renew

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$100 Fee

Reviewed by:

Application must be completed by vendor or contractor providing services or commodities pursuant to 71 IAC 5-1-1. Please note that any employees doing business on site, must be licensed as individual vendor employees (a $15 fee) using a separate application. Fingerprints may be needed. Fingerprint fee is determined based upon residency. Call for fee structure.

First Name

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 vendor Yes Partnership No Corporation

3. Has vendor ever operated under a different name/dba? If yes, give name(s) 4. Form of ownership: Other Sole Proprietorship

5. If vendor/contractor is a sole proprietor or partnership, please list* the owner and/or all partners in the following space provided (if additional space is necessary, please attach a separate page):

Last Name

* Note: The individual listed as owner in a sole proprietorship or all partners in a partnership, must also complete the MultiPurpose License Application as vendor employees.

6. Business address:
Street City State/Province Zip

Telephone number: (

)
Home

(

)
Business
(

(
)

)
Local Phone

7. Name of contact person for vendor 8. Social Security number or federal ID number
(Social Security Number is being requested to pursue statutory responsibilities and is voluntary.)

TID #

9.

Type of concession/business Has vendor 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

10. Yes No

(a) (b)

11. Yes No

If vendor is a sole proprietor and is married, has 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)

12.a) Yes No b) Yes No Yes c) No d) Yes No e) Yes No

Has vendor's racing license (or spouse's) ever been SUSPENDED, for more than five (5) days ? Has vendor (or spouse) every 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? Has vendor ever been RULED OFF or BARRED from a race track? If any question in 11 a, b, c, d or e was answered as YES, you must provide the following:
Date State Track Specific Violation Penalty

1 2

If additional space is needed in relation to any of the questions above, please attach a separate page.
~ Continued On Reverse Side ~

13. a) Yes No b) Yes No c) Yes No
Individual's Name

Have you (as a sole proprietor) or any directors, officers or partners of this company/partnership ever been ARRESTED? You must answer YES, even if charges where droped or dismissed. Are you or any of the individuals listed in question 12a currently on PAROLE or PROBATION? Are there CRIMINAL charges currently pending against you (or your spouse) or any directors, officers or partners of this company/partnership? If any question in 12 a, b or c was answered as YES, you must provide the following:
Date of Arrest State Arresting Agency Offense Outcome/Sentence

(1) (2) (3)

If you need more space to report additional information related to any of the questions above, please attach a separate page. 14. Please list the names of any employees who will be working on site. This includes anyone working at the race track or any facility under the jurisdiction of the Indiana Horse Racing Commission. Please print legibly!

(Please note that anyone working on site must be licensed individually. For more space, please attach a separate page.) 15. IHRC Rules Require Worker's Compensation Act Compliance. Licensed employers shall carry worker's compensation insurance covering their employees as required by 71 IAC 5-1-10. 16. PRIOR TO SUBMITTING THIS APPLICATION, YOU MUST BE APPROVED BY EITHER THE RACE TRACK/PERMIT HOLDER OR THE INDIANA HORSE RACING COMMISSION, DEPENDING ON WHO YOU ARE EMPLOYED OR CONTRACTED BY.
Signature of Race Track/Casino Management or Racing Commission

STOP

Approval is hereby granted by Date , 20
Title

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

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