Fillable Occupation License Application Form (Page 2 of 2) in pdf

6. ALL VENDOR, MANUFACTURER, DISTRIBUTOR, MANUFACTURER / DISTRIBUTOR or CIVIC ORGANIZATION APPLICANTS

I am the responsible licensee for ________________________________________________ and affirm that all applicable city, county, state and federal

(Company or Organization)

requirements, including but not limited to licenses and permits for conducting business by me and the above-named company, have been obtained and

the applicable license(s) to market all products and/or services offered by us.

Authorized Signer (Print name & sign): _______________________________________________________________________________________

7. UNDER 18 YEARS OF AGE (if applicable)

• Applicants under age 18 require signature of parent or legal guardian.

• Applicants for Owner under age 16 also require the parent / legal guardian to be licensed concurrently by the OHRC as an Authorized Agent.

Print parent / legal guardian’s name:_____________________________________ SSN:______________________________ and Date of Birth:_________________________

By signing, I give permission for licensure of this minor and assume full responsibility, including financial responsibility, for such licensure.

Signature of above-named parent / legal guardian: __________________________________________________________________ Date: _____________________________

8. WORKERS’ COMPENSATION ACT COMPLIANCE / RESPONSIBILITY STATEMENT --

ALL APPLICANTS MUST ANSWER



Do you employ any person(s) within the racetrack enclosure at any OHRC-Licensed racetrack?

YES NO

If “YES”, provide the following details and attach a copy of the Certificate(s) of Insurance to this application. Insurance Company:______________________________,

Agent:_______________________________, Agent’s area code and phone:____________________________, Policy number:______________________________________,

Expires:_____________, List all employees and their occupations at OHRC-licensed racetracks covered by the insurance above (attach additional sheet if necessary):________

9. JOCKEY AGENT or AUTHORIZED AGENT APPLICANTS

Name of Client

Client’s type of license

Representation Beginning Date

Representation Ending Date

10. OWNER, TRAINER, OWNER / TRAINER and OWNER / ASST. TRAINER APPLICANTS (Attach additional sheet if necessary)

Horse’s Name

Breed

Circle One

Trainer’s Full Name

Ownership Name on Certificate of Registration

Leased?

Own Train

Yes

Own Train

Yes

11. COMPLIANCE STATEMENT

ALL APPLICANTS MUST ANSWER

By the acceptance of a license issued pursuant to this application, I agree to comply with the rules of the Oklahoma Horse Racing Commission, the laws of the United States of America, the

State of Oklahoma, Municipalities and other subdivisions thereof, and consent to any provisions which may be contained in them for search, within the enclosure of an organization licensee,

of any premise which I may occupy or control or have the right to occupy or control and my personal property and effects including a personal search, and the seizure of any article, the

having of which within such enclosure may be forbidden by law or Commission or racetrack rule. I hereby request and authorize the Oklahoma Horse Racing Commission to conduct an

official investigation of my personal history and background, including through the OSBI and FBI. I understand that any investigation, the application, and any information submitted with

relation to my application, are subject to the Open Records Act of Oklahoma and shall be treated in accordance as such. I understand that, except where specific State or Federal statute

creates a confidential privilege, persons who submit information to public bodies have no right to keep this information from public access or reasonable expectation that this information will

be kept from public access. I hereby certify that I understand the above statements and further authorize all consumer reporting agencies to release to the Commission any information

requested by the Commission in connection with the background investigation and processing of this application. I hereby certify that all statements herein are complete and true. I

understand that failure to disclose all information completely and accurately may result in refusal to issue, denial or revocation of this license and/or other disciplinary action by a Board of

Stewards and/or the Commission. I have read and understand the above statements and conditions and knowingly and voluntarily attach my signature hereunto.





ALL APPLICANTS MUST READ & SIGN

____________________________________________________________________

Applicant’s Signature

(or Authorized Agent if Applicant is under age 16 years)

12. AFFIDAVIT VERIFYING LAWFUL PRESENCE IN THE UNITED STATES (All must complete if in U.S. during the license period)

Instructions for required verification of United States citizenship

qualified alien status in the United States: All natural persons fourteen (14)

years of age or older and present in the United States, applying for a license with the Oklahoma Horse Racing Commission are required, by the provisions

of 56 O.S. Supp. 2007 § 71, to provide the Commission with verification of lawful presence in the United States by executing one of the statements below.

I, ____________________________________________, of lawful age, being first duly sworn, upon oath states, under penalty of perjury, as follows:

(PRINT Applicant’s Name)

I am a United States Citizen.

I am a qualified alien under the Federal Immigration and Naturalization Act, and I am lawfully present in the United States.

Provide a copy of your Passport / Visa / Alien Registration document and write the number & expiration date: ____________________________



____________________________________________________________________

________________________________________________________________________

Applicant’s Signature

NOTARY PUBLIC

Signed or attested before me this_____day of_______________, 20____

My Commission expires: __________________________________