Occupation License Application Form
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Make payable to:
Oklahoma Horse Racing Commission
OCCUPATION LICENSE APPLICATION
2401 NW 23 Street, Suite 78, Oklahoma City, OK 73107
(405) 943-6472
LICENSE FEES
CHOOSE THE CATEGORY BELOW YOU ARE APPLYING FOR
$50 annual -or- $120 triennial, plus
Owner
Owner / Trainer
Trainer
Jockey
Blacksmith
Veterinarian
$41 fingerprint processing fee, if appl ►
$50 annual, plus
Appr.
Asst.
Owner /
Jockey
Auth.
Racing
Track
Bloodstock
Vendor
$41 fingerprint processing fee, if appl ►
Jockey
Trainer
Asst. Trainer
Agent
Agent
Official
Mgmt
Agent
Groom/
Exercise
Pony
Horse
Asst. Racing
Valet
Outrider
Admin.
Hotwalker
Rider
Rider
Industry Rep.
Official
$25 annual, plus
$41 fingerprint processing fee, if appl ►
General Svc: (Must Specify Dept.)
Conc. /
Vet.
Vendor
Mutuels
Security
Food Svc.
Assistant
Employee
Vendor
Manufacturer
Distributor
Manufacturer / Distributor
$150 annual, plus
Key Executive
$41 fingerprint processing fee, if appl ►
▼
(These are authorized signers for same category employees below)
$300 annual, plus
Vendor
Manufacturer
Distributor
Manufacturer/ Distributor
FP proc fee, If applicable
Employee
Employee
Employee
Employee
$125 annual, plus
$41 fingerprint processing fee, if appl ►
Facility Employee: (Must specify dept such as: security, mutuel, food svc, etc )
BSA
1. APPLICANT
Full Legal Name:
Nickname, alias, or other name used
LAST,
FIRST
MIDDLE
MAIDEN
Address
Social Security Number
(Street Address)
(City)
(State)
(Zip)
Daytime area code & phone number
Cell area code & phone number
Fax area code & phone number
Date of Birth (mm-dd-yyyy)
Age
(
)
(
)
(
)
Sex
Race
Height
Weight
Eyes
Hair
Place of Birth (City, State, Country)
Profession or occupation other than horse racing
Driver’s license number & issuing state
Are you presently practicing veterinary medicine in Oklahoma?
Email Address
YES
NO
Vet License #____________ expires______________
2. COURT RECORD
Have you ever been convicted of a felony? All convictions must be listed including: date, county, state, offense and sentence. Attach a copy of the court
YES
NO
record.
Are you currently on any type of probation, parole, supervised release or suspended sentence for a felony offense? Attach a copy of the court record.
YES
NO
3. PRIOR LICENSURE
OFFICE USE ONLY
Have you ever held a horse racing / gaming facility license in any racing jurisdiction, including Oklahoma? List the
New
-or-
Renewal Yr_________
YES
NO
state/country, year and license type.
Effective_______________________
Have you ever been ineligible for a horse racing / gaming facility license, suspended for more than seven (7) days, had
Expires ___12-31-_______________
your license revoked, been fined over $100, ruled off, excluded/ejected, or discharged, from any racing jurisdiction,
YES
NO
including Oklahoma? List the date, state/country, nature of violation, suspension, and fine. Attach additional sheet if
Track___________ Clerk__________
necessary.
FP:
4. SPOUSE (must be completed if married)
Spouse’s Social Security Number (If known)
LAST,
FIRST
MIDDLE
MAIDEN
Legal Name:
Lic Rec #______________________
Has your spouse ever held a horse racing / gaming facility license in any racing jurisdiction, including Oklahoma?
FP Rec #______________________
YES
NO
List the state, country, year and license type.
Stew/Agent_____________________
Has your spouse’s racing / gaming facility license ever been suspended, denied, or revoked in any racing jurisdiction,
including Oklahoma? List the date, state/country, nature of violation, suspension, and fine.
YES
NO
Ruling:
YES
-or-
NO
5. EMPLOYEES (Complete all requested – your employer / authorized-signer must sign)
I am the employer of this license applicant and evidence of Workers’
Print Employers name: _____________________________________________________________
Compensation Insurance or other self-insurance coverage is attached
hereto which provides evidence of security for liability for such employee
Print Company Name (if applicable): __________________________________________________
OR I have previously filed such evidence with the OHRC providing
coverage for the employee and I have submitted this employee’s name to
Employers SSN: __________________________________________________________________
the OHRC OR I have signed the OHRC Waiver of Responsibility
Statement certifying that the employee does not subject me to liability
Employer / Authorized-Signer:
under the Workers’ Compensation Laws of Oklahoma.
__________________________________________________
Page 1 of 2
OHRC145L 9/19/13-LH
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Parent category: Business