State Of Florida Department Of Business And Professional Regulation Division Of Pari-Mutuel Wagering
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1
2DBPR PMW-3125 – Individual Occupational License Renewal Application
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DIVISION OF PARI-MUTUEL WAGERING
Instructions: Please review this application thoroughly and complete every section that pertains to you. All applicable questions
must be answered in full. Place any additional information on separate sheet of paper and attach to this form. Print clearly in
black or blue ink. Do not write in the space labeled “For Division Use Only.” Licenses expire June 30th of each year. Fees may
be paid by check or money order only and should be made payable to DBPR in U.S. funds. Call 850.488.3211 if you need
any assistance with renewing your license.
TO BE COMPLETED BY ALL APPLICANTS
Social Security Number
Birth Date
Gender:
Number of License Years:
(MM/DD/YYYY)
Male
Female
1-year
3-Year
/
/
Last Name
First
Middle
Title
Suffix
Yes
No
Since the submission of your last application, have there been any changes to your name, address, or
telephone number? If yes, then provide your updated information on the back of this form.
Industry of occupation:
Type of Occupation (for example, owner, trainer, etc.):
Greyhound
Quarterhorse
Jai Alai
Harness
Thoroughbred
Yes
No
Since the submission of your last application, have you been convicted of or had adjudication withheld for any
crime, or pled guilty or nolo contendere to any criminal charges against you? If yes, you must complete the
DBPR PMW 3120 form instead of this form.
Yes
No
Since the submission of your last application, have you been convicted of bookmaking, illegal gambling or
cruelty to, or neglect of, animals? If yes, you must complete the DBPR PMW 3120 form instead of this form.
Yes
No
Since the submission of your last application, has your pari-mutuel license been suspended, revoked, or denied
in this or any other state or country? If yes, you must complete the DBPR PMW 3120 form instead of this form.
Yes
No
Since the submission of your last application, is there any reason that the State of Florida or another state or
country will not issue you a pari-mutuel occupational license? If yes, you must complete the DBPR PMW 3120
form instead of this form.
Yes
No
Since the submission of the your last application, have you voluntarily relinquished your pari-mutuel or gaming
license in lieu of prosecution in this or any other state or country? If yes, you must complete the DBPR PMW
3120 form instead of this form.
TO BE COMPLETED IF APPLICANT IS A DISABLED WARTIME VETERAN
Yes
No
Are you an honorably discharged, disabled U.S. Military wartime veteran pursuant to Sections 205.171 &
1.01(14), Florida Statutes, or the un-remarried spouse of a deceased honorably discharged, disabled wartime
veteran under this definition? If yes, contact a Division Official at the facility where you are applying or call
850.488.3211 for further information.
TO BE COMPLETED BY CARDROOM APPLICANTS ONLY
Yes
No
Since the submission of your last application, have you been convicted of, or had adjudication of guilt withheld
for, a felony or misdemeanor involving forgery, larceny, extortion or conspiracy to defraud or filing false reports
to government agency, racing or gaming commission or authority, in this state or any other state under the laws
of the United States? If yes, you must complete the DBPR PMW 3120 form instead of this form.
FOR DIVISION USE ONLY
License Code_________ License #_____________ File #___________ App # _________
License Year__________
Association Code_____________
Date Received_________________
Entered By______________
License Fee______________
FP Date________________
FP Fee__________
Total Fee___________
ARCI checked
DBPR PMW-3125, adopted --/-- at Rule 61D-10.001, F.A.C., and 61D-12.001, F.A.C.
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