Form Oscr 1000 - Ohio State Racing Commission License Application (Page 2 of 2) in pdf

At this time are you under suspension, ruled off, or ineligible to participate in racing by any racing organization, association,

commission or recognized authority in the United States or elsewhere? If yes, state when, where and by whom the rulings were

made and the offense(s) charged. Attach additional sheets if necessary.

Yes

Within the past five years has your racing license been denied, suspended or revoked, or have you been ruled ineligible for licensing by

any racing commission or other racing authority? If yes, provide particulars. Attach additional sheets if necessary.

Yes

Have you ever been ejected from or denied the privileges of a racetrack? Attach additional sheets if necessary.

Yes

The following to be answered by apprentice jockeys only. Name of stable with which you have had one year of previous service?

Stable Name

Owner Of Stable

Number Of Winners Ridden

Date of First Winner

Location of First Winner (Racetrack)

To be answered for an authorized or jockey agent license by the person or persons (owner, jockey, etc.) appointing the authorized agent.

I Hereby Appoint (Name):

Address (Number and Street)

City

State

Zip Code

Year

To act as my authorized agent/jockey agent for the year written in at the right in all matters pertaining to the

racing of my horse under the rules, regulations and conditions of the state racing commission and the laws of the state.

I do hereby authorize my said agent to act for me subject to the following limitations:

Signature(s)

State Limitations, If Any

It is hereby understood that I assume responsibility for the acts of my authorized agent or jockey agent in connection with this authority.

This _______ Day of ___________________________, 20_________

Signature of Appointor

Groom application must be signed by employer.

Date

Printed Name of Employer

Signature of Employer

All applicants for owners and/or trainers licenses must answer the following: Do you carry workers compensation insurance

coverage for all persons you employ?

Yes

If you do not carry workers compensation insurance check the proper reason:

No Employees

Contract Labor

Read before signing. In affixing my signature to this application, I certify I have read and, to the best of my knowledge, correctly

and truthfully answered each of the questions or statements on this application and I agree to follow the rules of the Ohio

State Racing Commission. I hereby consent to the search of my person, my personal effects and places that I have the right to occupy

and have control over while on the premises of a permit holder. I agree to provide a breath or urine sample in accordance with the Ohio

Rules of Racing. I consent to the seizure of any illegal article or substance forbidden by the Ohio Rules of Racing found in my possession or

in a location under my control on the premises of a permit holder. My refusal to consent to any searches and seizures described above will

automatically result in the immediate revocation of my commission license and my being ruled off all tracks in Ohio for the remainder of the

calendar year, and is sufficient reason for the Ohio State Racing Commission to refuse to issue me a license for a period not to exceed two

calendar years.

Date of Application

Printed Name of Applicant

Signature of Applicant

OSRC 1000 12/11)

Form Oscr 1000 - Ohio State Racing Commission License Application Page 2

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