License Form I New Jersey Racing Commission Page 2
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Section A
1. ( ) OWNER
31. ( ) OWNER - THREE YEAR
The Laws of New Jersey require you to carry Workers Compensation Insurance for horse racing industry employees. Such Insurance is automatically
provided by the Horse Racing Injury Compensation Board for horse racing purposes only. Owners will be assessed the cost of this insurance pursuant
to N.J.A.C. 13:73-1.1 et.seq.
What is your occupation/position?
Employer’s Name
Bus. Tel. No. (
)
Employer’s Address
Employer’s type of business:
(Street)
(City)
(State)
(Zip)
Name of your Bank
Address of Bank
(street)
(City)
(State)
(Zip)
How long have you owned race horses?
years
Is this your first Owner’s License in New Jersey? ( ) no ( ) yes
How is Ownership to listed on program?
Who is your trainer?
(Last)
(First)
(Middle)
(Sr,Jr,etc.)
(Space for other)
List all horses owned or leased by you, wholly or in part. Specify lease (L) or purchase (P) in appropriate space.
A copy of lease agreement(s) must be attached to the application. (Use additional page, if necessary)
HORSE’S NAME
NAME & ADDRESS OF LESSOR OF THE HORSE OR FROM WHOM PURCHASED
L/P
1.
2.
3.
4.
5.
Do you have any agreement for the distribution of any horse’s winnings with someone other than those listed above? ( ) yes ( ) no
If so give name and address of person(s).
If racing under any form of corporate or multiple ownership, indicate all racing interest or entities in which you have any interest.
Stable or Other Racing Entity
% of Interest
1.
2.
If applicant is married, please furnish the following information concerning your spouse:
Full Name
(Last)
(First)
(Middle)
(Sr,Jr,etc)
(Maiden name)
Date of Birth _____/______/___________
SSN/CSSN _________________________________ * Spouse’s Occupation: _____________________________
Employer’s address
(Street)
(City)
(State)
(Zip)
Employer’s Tel. No. (
) ________________________________________ Employer’s Business: ________________________________________________
To the best of your knowledge, has your spouse ever been convicted:
( ) yes ( ) no
(a) of a crime?
( ) yes ( ) no
(b) bookmaking?
( ) yes ( ) no
(c) use, sale or possession of narcotics?
( ) yes ( ) no
(d) Has your spouse ever been ruled off or suspended from a racing jurisdiction?
If you answered yes to any of the above please give particulars below. (Use additional page if necessary)
DATE
JURISDICTION
CHARGE
DISPOSITION
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