License Form I New Jersey Racing Commission
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N.J.R.C. USE ONLY
N.J.R.C. USE ONLY
LICENSE FORM I
LIC. NO.
LOC.
OPER
NEW JERSEY RACING COMMISSION
YR
LOC
NUMBER
DATE
P.O. BOX 088
RCPT. NO.
RCPT NO.
YR
LOC
NUMBER
TRENTON, N.J. 08625-0088
609 984-1554
RCPT. DATE
OPER.
CASH $
ID NO.
CHECK
$
( ) ORIGINAL
( ) RENEWAL
MO
$
( ) HARNESS
( ) THOROUGHBRED
CHECK APPROPRIATE CATEGORIES
ARE YOU A MEMBER OF THE U.S.T.A? ( ) YES ( ) NO
U.S.T.A. NO. ____________________________________
1. ( ) Owner $50
5. ( ) Driver/Trainer $50
10. ( ) C.I.D. $10
14. ( ) Valet $20
31. ( ) Owner $150/3 yr license
6. ( ) Jockey $50
Dept.
15. ( ) Plater $20
2. ( ) Trainer $50
7. ( ) Jockey Apprentice $30
16. ( ) Vendor $50
3. ( ) Asst. Trainer $30
8. ( ) Jockey Agent $50
11. ( ) C.I.D. - Vendor $10
23. ( ) NJRC Veterinarian
4. ( ) Driver $50
9. ( ) Stable Employee $5
Employer
25. ( ) NJRC C.I.D.
27. ( ) NJRC Official
12. ( ) Pari Mutuel $25
40. ( ) Exercise Rider
Circle U.S.T.A. Driver Type: A, AM, L, M, P, Q, V (Expiration Date _______________________________)
13. ( ) Veterinarian $50
PLEASE READ CAREFULLY BEFORE FILLING OUT APPLICATION
In making this application for license or to otherwise participate in racing in the State of New Jersey. It is understood that an investigative report may be made whereby
information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom you
are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living, which may be applicable. You have the right
to make a written request, within a reasonable period of time, for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
FBI FINGERPRINT DISCLOSURE
As part of the above referenced investigation, NJRC may require that you submit a completed federal fingerprint card, which it will use to check the criminal history records of the
federal bureau of investigations (FBI). Before making any determination regarding suitability for licensing, you will be provided an opportunity, within a reasonable time period,
to complete or the challenge the accuracy of any information obtained in the fbi record. Procedures for correcting or updating FBI identification records are set forth in Title 28, C.F.R.,
sec. 16.34.
Fair Credit Reporting Act
Public Law No. 91-508
APPLICATION MUST BE TYPED OR PRINTED IN INK!
All Questions Must Be Answered
SSN/TIN/CSSN ________________________________*
NICKNAME: ___________________________________
(Social Security Number, Tax ID, Canadian)
Full Name
(Last)
(First)
(Middle)
(Sr,Jr,etc)
(Maiden name)
Permanent Address
(Street)
Birthdate _____/_____/________
(City)
(State)
(Zip)
Mo.
Day
Yr.
Home Tel. No. (
)
Height
Weight
Place of birth
Eyes
Hair
(City)
(State)
Present Address
Sex: M /
F Comp.
(Street)
(City)
(State)
(Zip)
Person to be notified in case of emergency:_____________________________________
Telephone: (
)
Citizen of United States? ( ) Yes ( ) No
Citizen of
Immigration I.D. No.
Scars, marks, glasses, etc.
1. In what state and year were you first granted a license?
state_________
year ________
( ) yes ( ) no
2. Have you been licensed previously in New Jersey? year ___________
( ) yes ( ) no
3. Are you licensed in another state?
Where? state ______,__ ____, _______, _______, _______,
( ) yes ( ) no
4. Have you ever been denied a license? Where & When?
state_______ year________
state_______ year_________, state _________ year _________, state_______ year________
( ) yes ( ) no
5. Have you ever been fined $100 or more, ruled off, suspended or otherwise debarred by any recognized turf authority in the U.S. or elsewhere?
If so give particulars. (Use additional page if necessary) _____________________________________________________
__________________________________________________________________________________________________
( ) yes ( ) no
6. Have you ever owned or operated a handbook or a bookmaking establishment or been connected with bookmakers? If
so give particulars. (use additional page, if necessary) ______________________________________________________
__________________________________________________________________________________________________
( ) yes ( ) no
7. Has an indictment or information been returned, or complaint made against you by the U.S. or any state, charging sale, use
or possession of narcotics? If so give particulars. __________________________________________________________
__________________________________________________________________________________________________
( ) yes ( ) no
8. Have you ever been arrested or has a summons pertaining to a criminal complaint ever been filed against you?
( ) yes ( ) no
9. Have you ever been convicted of a crime?
If you answered yes to questions #8 and/or #9 please give the following information for each arrest:
DATE
JURISDICTION
CHARGE
DISPOSITION
__
FOR EACH CONVICTION DESCRIBED ABOVE, A CERTIFIED COPY OF THE COURT COMPLAINT, INCLUDING INDICTMENT AND/OR CERTIFIED COPY OF THE DISPOSITION MUST BE
ATTACHED TO THE APPLICATION. IF PAPERS ARE NOT ATTACHED, YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE AND WILL NOT BE PROCESSED.
ALL APPLICANTS MUST COMPLETE APPROPRIATE SECTION(S) FOR CATEGORY(S) OF LICENSE(S) DESIRED:
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