License Form I New Jersey Racing Commission Page 4

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PAGE 4

Section E

9. ( ) STABLE EMPLOYEE

List Name of Trainer _________________________________________________________________________________________________________________

List Name & Address of present and previous employers for the past three years.

Name

Street

City/State/Zip

Dates of Employment

_____________________________________________________________________________________________________________________________________________

Section F

10. ( ) C.I.D.

11. ( ) C.I.D-VENDOR

12. ( ) PARI-MUTUEL

13. ( ) VETERINARIAN

14. ( ) VALET

( ) N.J.R.C.

List Dept. or Employer:______________________________________________ Position __________________________________________________________

List Name & Address of present and previous employers for the past three years.

Name

Street

City/State/Zip

Dates of Employment

_____________________________________________________________________________________________________________________________________________

ALL PERSONS APPLYING FOR A PARI-MUTUEL EMPLOYEE LICENSE MUST ANSWER THE FOLLOWING QUESTIONS:

Have you incurred any outstanding indebtedness to any permit holder conducting race meetings in the State of New Jersey? (

) no (

) yes

If yes, state the exact amount of said indebtedness. $ _____________________________

Any person answering the preceding two (2) questions in the affirmative shall be required as a condition precedent to licensure to provide the commission with documentation from

the mutuel manager for the permit holder indication said indebtedness has been or is being adjusted to the satisfaction of the permit holder.

(Dept. Head Approval)

Section G.

15. (

) PLATER

16. (

) VENDOR

If applying for a (PLATER LICENSE) please complete the following:

List Name & Address of present and previous employers for the past three years.

Name

Street

City/State/Zip

Dates of Employment

_____________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________

If applying for a (VENDOR LICENSE) please complete the following:

Type of Business: (

) Sole Proprietorship

(

) Partnership

(

) Corporation

List the name of your business _________________________________________________________________________________________________________

List your business address ____________________________________________________________________________________________________________

List the nature of your business _______________________________________________________ Business Tel. No. (

) ____________________________

List name and addresses of officers: (use additional page, if necessary)

1. Name _____________________________________________ Address _____________________________________________________________________

2. Name _____________________________________________ Address _____________________________________________________________________

3. Name _____________________________________________ Address _____________________________________________________________________

Name of your Bank __________________________________________________________________________________________________________________

Address of Bank ____________________________________________________________ APPROVAL BY ASSOCIATION TO OPERATE AT TRACK:

(Street)

____________________________________________________________

_____________________________________________________

(City)

(State)

(Zip)

(Signature)

ALL APPLICANTS MUST COMPLETE APPROPRIATE SECTION(S) FOR CATEGORY(S) OF LICENSE(S) DESIRED!

ALL APPLICANTS MUST SIGN THIS SECTION

ANY PERSON MAKING A FALSE, MISLEADING OR INCOMPLETE STATEMENT ON AN APPLICATION FOR LICENSE OR REGISTRATION OR IN A WRITTEN OR ORAL

EXAMINATION IN CONNECTION WITH SUCH AN APPLICATION MAY BE DISCIPLINED AS PROVIDED FOR IN THE RULES AND REGULATIONS OF THE NEW JERSEY

RACING COMMISSION.

I hereby certify that I am not under suspension or in bad standing with any recognized turf body and that I have read the foregoing application and know the contents thereof,

and that every statement contained herein is true and correctly set forth.

Steward’s Recommendation:

_______________________________________________________

____________________________________________________

(Signature of Applicant)

_______________________________________________________

____________________________________________________

(Date)

_______________________________________________________

THE ISSUANCE OF A LICENSE BY THE NEW JERSEY RACING COMMISSION DOES NOT NECESSARILY ENTITLE THE HOLDER TO ANY RIGHTS OR

PRIVILEGES AT THE PREMISES OF ANY LICENSED TRACK.

*VOLUNTARY PROVISION OF SOCIAL SECURITY NUMBERS IS REQUESTED (NJAC 70-4.22 AND 71-7.37) AND WILL BE USED AS A SECONDARY