Form Oscr 1000 - Ohio State Racing Commission License Application
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1
2Stewards Or Judges
Ohio State Racing Commission
License Number
77 S. High St. -- 18th Floor
Columbus, Ohio 43215-6108
Inspector
Date Issued
(614) 466-2757 – Fax (614) 466-1900
Ohio State Racing Commission License Application
In Accordance With Commission Rules and Regulations I Hereby Apply for the Following License.
Check one:
Thoroughbred
Harness
Quarter Horse
Fair
Last Year Fingerprinted
State or Province Fingerprinted For
Type of License (Describe)
License Fee (See Schedule)
Gender
E-Mail Address
Male
Female
Last Name (Please Print)
First
Middle Initial
Social Security Number
Permanent Address:
Number and Street
City
State
Zip Code
Present Address:
Number and Street
City
State
Zip Code
Employer Name, Address and Telephone Number
Date of Birth (
Home Phone Number
Cell Phone Number
Month / Day / Year)
/
/
Make of Car
License Number
State
Other than traffic, in the last ten years have you been arrested or convicted or served time on any criminal charge?
Yes
No
If so, provide all information concerning the charge or charges, including date, location and final disposition. Attach
additional sheets if necessary.
Jurisdiction / License Number
Do you have a valid racing license from another jurisdiction?
Yes
No
USTA License Number
Do you have a United States Trotting Association license?
Yes
No
Name of Trainer:
List horses in your care and all persons, including yourself, who hold any interest in those horses.
Name of Horse
Owner
Address
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Parent category: Business