Free OTD-OT app '08.pmd - Indiana

OFFICE USE ONLY

INDIANA HORSE RACING COMMISSION
License Application for Combination Owner License
For use ONLY if you're an Owner/Trainer or Owner/Trainer/Driver

License Year:

New Date Total Fees Cash Clerk Reviewed by: /

or Renewal /

Check

M.O. F.P.

State Form 46651 (R19 / 5-09) Approved by State Board of Accounts, 2008

$60 Fee

Owner/Trainer
First Name

Owner/Trainer/Driver

Breed(s): ___SB ___ TB ___QH
Please check your license category and breed above. Application must be completed to issue license. Please note if fingerpirnts are necessary, there will be an additional charge of $36

1.

Have you been previously licensed by the Indiana Horse Racing Commission (IHRC)? If yes, please list your IHRC number here: #

Yes

No

2. Name of applicant

Last

First

Middle

Maiden

3. Have you ever used an assumed name or been known by another name? If yes, give name(s)
Last Name

Yes

No

4. Permanent address:
Street City State/Province Zip/Country

5. Local address:
City

(Need only complete this question if Permanent Address differs from Local)

State/Province

Zip/Country

6. Telephone numbers: (
OFFICE USE ONLY

)
Home #

(

)
Business #

(

)
Fax #

7. Are you married?

Yes

No If yes, give full name of spouse, including maiden name:

8. 9.

Person to be notified in case of emergency: Social Security Number Sex Height Weight Color Hair

Telephone: ( Color Eyes

) Birth Date Age*

Social Security Number is being requested to pursue statutory responsibilities and is voluntary.

10. USTA Number

USTA Exp. Date

(USTA question above pertains to Standardbred licensees only. Please circle designation to the right.)

Trainer Designation: Driver Designation:

G A

L P

CD QF

CD

11 . If you listed "Indiana" as the state of your permanent address to question #4 above, you must answer the following: Yes Did you file an individual Indiana Yes Will you file an individual Indiana No State income tax return for 2007? No State income tax return for 2008? 1

12. Are you a U.S. Citizen?

Yes

No

If no, of what country are you a citizen?

Immigration registration number (if applicable) A13. Give the following information relative to your current employer. If self-employed, so indicate:
Employment Dates Name of Employer Address (Street, City, State, Zip)

14. Yes No

Have you been previously licensed by any other racing jurisdiction (excluding Indiana)? If yes, give the following information on current and most recent license(s):
Date Type (occupation) State/Province/Country License Number

(a) (b) 15. Yes No If married, has your spouse been previously licensed by another racing jurisdiction? If yes, give the following information on his/her current and most recent license(s):
Date Type (occupation) State/Province/Country License Number

(a) (b) 16. a) Yes No b) Yes No c) Yes No d) Yes No e) Yes No

Have you ever been SUSPENDED for more than five (5) days? Have you ever been FINED over $100? Has your racing license (or your spouse's) ever been DENIED or REVOKED? Do you (or your spouse) have PENDING racing violations? Have you or your spouse ever been RULED OFF or BARRED from a race track? If any in 16 a, b, c, d, or e was answered as YES, you must provide the following:
Date State Track Specific Violation

(1) (2) 17. a) Yes No b) Yes No c) Yes No (1) (2) (3) Have you (or your spouse) ever been ARRESTED? You must answer YES, even if charges were dropped or dismissed. Are you (or your spouse) currently on PAROLE or PROBATION? Are there CRIMINAL charges currently pending against you? If any question in 17 a, b or c was answered as YES, you must provide the following for each incident:
Date of Arrest State Arresting Agency Offense Outcome/Sentance

If additional space is needed in relation to any of the questions above, please use a separate sheet of paper and submit it with this form.
2

18. IHRC Rules Require Worker's Compensation Act Compliance.
Licensed employers shall carry worker's compensation insurance covering their employees as required by 71 IAC 5-1-10. If you are not sure your employees need to be covered, please contact the Indiana Worker's Compensation Board at 317-232-3808.

19. Statement of Ownership
Must be completed by all applicants. All names below must read as they are registered with the USTA, Jockey Club or AQHA. NO owner may be licensed as a horse OWNER unless s/he, during the period of licensure: a) is the owner or lessee of Record of a properly registered racehorse(s); or b) has an interest as a part owner or lessee of a properly registered racehorse; and c) which such racehorse(s) s/he intends to race at an IHRC licensed race track during the period of licensure and is in the care of a Trainer who is, or will be, an IHRC licensed Trainer. Horse's Name Age Trainer's Full Name Ownership Name on Certificate of Registration

If additional space is required, please use a separate sheet of paper and submit it with this form.
If more than one person's name appears on the Certificate of Registration as Owner, or if the Owner appearing on the Certificate of Registration is other than that of an individual (in other words, it's a stable or corporation), an additional form must be completed and filed with the Commission prior to entry time for such horse at any IHRC licensed race track. 20 a. Yes No Are any of the horses listed above owned by more than one individual (excluding husband & wife)? If yes, please list the name, address and phone number of the Managing Partner:
(street address) ( (city, state, zip) ) (phone)

Attention:

b.

Are there any owners with a less than 5% ownership interest?

Yes

No

21. Yes
No

Is your horse leased?

Name of Lessor Name of Lessee

22. Yes
No

Will you have an Assistant Trainer(s) assigned to your horse(s)? If yes, please list below:
Name of Assistant Trainer(s): Will you be appointing an Authorized Agent? (Agent must be licensed as an Authorized Agent by IHRC). If yes, give name below and complete separate authorized agent form. IHRC License # 3

23. Yes No

Name of Authorized Agent:

Indiana Horse Racing Commission Affidavit
I understand that participation in racing in Indiana is a privilege, not a right, that the license issued pursuant to this Application is subject to conditions precedent as set out in the applicable Indiana Rules and Regulations, and that my failure to comply therewith, including but not limited to misstatements or omissions in the foregoing application, shall be grounds for immediate revocation or suspension of such license. By acceptance of said license, I agree to abide by the statutes of the State of Indiana relating to racing, the applicable Indiana Rules and Regulations and rulings or decisions of the Judges/Stewards with the knowledge that rulings or decisions of the Judges/Stewards shall remain in force until reversed or modified by the Indiana Horse Racing Commission. I hereby acknowledge that I will be subject to the searches, either in my presence or absence, provided for in Indiana Code 4-31-13, as amended, and the Indiana Rules and Regulations that authorize personal inspections, inspection of any personal property, and inspections of premises and property related to my participation in a race meeting by persons authorized by the Indiana Horse Racing Commission. I also acknowledge that I may be requested to provide a breath or urine sample in accordance with Indiana Code 4-31-8, as amended, and the applicable Indiana Rules and Regulations. I further acknowledge that the Indiana Horse Racing Commission may seize any article or substance which is found in my possession or control or in a location under my control which may be forbidden or is against the applicable Indiana Rules and Regulations. I hereby waive all claims and remedies with the exception of those provided for by the Indiana Administrative Orders and Procedures Act (contained at Indiana Code 4-21.5-1, et seq.), and the applicable Indiana Horse Racing Commission Rules arising therefrom against the Indiana Horse Racing Commission and its members, employees and agents and the racing association on whose premises the search and/or seizure is made and the officials, employees and agents of such association. I hereby certify that I have read the foregoing Application and affirm that every statement contained therein is true and correctly and completely set forth. I do hereby authorize the Indiana Horse Racing Commission, the Indiana State Police, the Indiana State Department of Revenue and the Federal Bureau of Investigations to investigate and verify all information contained in this Application.

Signature of Applicant *

Date

E-Mail Address

* For Minors Only
*In accordance with 71 IAC 5-2-1, if applicant is under 18 years of age, this Application must be signed by applicant's Parent or Legal Guardian and acknowledged by a notary. By signing, the Parent or Legal Guardian hereby assumes responsibility for meeting all financial, contractual or other obligations relative to all racing activities of the applicant. Additionally, the parents or legal guardians of an applicant for an owner's license under the age of eighteen (18) must be licensed as an owner.

Signature of Parent or Legal Guardian *
Subscribed and sworn to before me this day of

Date
, year
. State: County

Notary Public

Expiration Date

c/o Hoosier Park, 4500 Dan Patch Circle Anderson, IN 46013 P: 765-609-4855 F: 765-683-2565

~OR~
4

c/o Indiana Downs, 4425 N 200 W Shelbyville, IN 46176 P: 317-713-3350 F: 317-713-3355