Application For Horse Racing Licence And Registration Page 2

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Gaming Policy and Enforcement Branch

Application for Horse Racing Licence and Registration

SECTION 2 – DETAILS OF LICENSEE AUTHORIZATIONS

Authorized agent(s) name(s):

Trainer(s) name(s):

Jockey’s agent(s) name(s):

SECTION 3 – TRAINED OR OWNED HORSES ON FILE WITH THE RACING SECRETARY

Trained or owned horses: (list horses on file with the Racing Secretary)

Name of horse:

Name of owner / partnership / stable / company:

SECTION 4 – DISCLOSURE

Full disclosure of all incidents and offences is required, including Young Offender information pursuant to Section 119(1)(o) of the Youth Criminal Justice

Act. Failure to fully disclose all incidents and offences is deemed sufficient grounds to deny your application.

1. Have you in the last 10 years,

Arrested

Yes

in any jurisdiction, been:

Stopped or Detained (such as for shoplifting or impaired driving)

Yes

Charged with any criminal offence, whether found guilty or not

Yes

Diverted or received Alternate Justice (such as for theft, shoplifting)

Yes

Convicted of any criminal offence, regardless of the sentence

Yes

Investigated by police, loss prevention or other authority for any criminal offence

Yes

Cases: (complete this section if you answered YES to any of the above – provide details as indicated below – list all cases without exception including

those in which you were not charged or convicted – attach a separate sheet if more space is required)

Date of Arrest / Detention:

Location:

(YYYY-MM-DD)

Age:

Charge / Claim:

(City, Prov / State)

Disposition:

Arresting Agency:

2. Have you, in any racing jurisdiction, been denied any licence or had any licence revoked?

Yes

3. Have you, in any racing jurisdiction, had any fines or suspensions?