Form OSRC1000 "Ohio State Racing Commission License Application" - Ohio

What Is Form OSRC1000?

This is a legal form that was released by the Ohio State Racing Commission - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2011;
  • The latest edition provided by the Ohio State Racing Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OSRC1000 by clicking the link below or browse more documents and templates provided by the Ohio State Racing Commission.

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Download Form OSRC1000 "Ohio State Racing Commission License Application" - Ohio

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Stewards 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
www.racing.ohio.gov
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
Stewards 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
www.racing.ohio.gov
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
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
No
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
No
Have you ever been ejected from or denied the privileges of a racetrack? Attach additional sheets if necessary.
Yes
No
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
No
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)
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