Form ADR205 "Authorized Agent Appointment" - Arizona

What Is Form ADR205?

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

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Arizona Department of Gaming - Division of Racing;
  • 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 fillable version of Form ADR205 by clicking the link below or browse more documents and templates provided by the Arizona Department of Gaming - Division of Racing.

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Download Form ADR205 "Authorized Agent Appointment" - Arizona

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ARIZONA DEPARTMENT OF GAMING - RACING DIVISION 1110 W. Washington, Suite 450 Phoenix, AZ 85007 Telephone (602) 364-1700
FOR RACING DIVISION USE ONLY
Applicant ID#__________________ Issue Date: __________________
Expiration Date: _______________
AUTHORIZED AGENT APPOINTMENT
A
A
A
MAY NOT
A
A
N APPOINTMENT OF AN
UTHORIZED
GENT FOR ONE CATEGORY OF ACCOUNT
BE UTILIZED TO FORM AN
UTHORIZED
GENT FOR ANY OTHER
.
A
A
MUST
.
ACCOUNT
A SEPARATE
UTHORIZED
GENT FORM
BE SIGNED BY ALL PRINCIPALS FOR EACH SEPARATE AND DISTINCT ACCOUNT
Name of Agent to be Appointed: _______________________________________
License #: ____________________
Please Print
Authorized Agent for:
Individual Owner
Multiple Owners
Corporation
Stable Name __________________________________
Print Stable Name
Name of Principal: ___________________________________________________
License # ____________________
Please Print
Authorized Agent May:
Yes Conduct ALL matters relating to my racing animals, with NO limitations or restrictions
If LIMITATIONS/RESTRICTIONS pertain to this appointment, complete the following:
(All statements A-F must be answered)
A.
Claim horses in my/our name
Yes
No
B.
Sell, buy, or transfer horses without written consent
Yes
No
C.
Receive and endorse checks made payable to me/us
Yes
No
D.
Direct the transfer of money in my/our account
Yes
No
E.
Have checks made payable to himself/herself from my/our account
Yes
No
F.
Other business
-
Yes
No
Describe other business indicating limitations or restrictions, if any: ______________________________
I hereby appoint the person indicted above to act for me on matters relating to my race animals in accordance with Arizona Racing Commission
Rules. I assume full financial responsibility for the acts of my Authorized Agent in connection with this appointment. In granting this authority, I
release the Arizona Racing Commission and the Arizona Department of Gaming/Racing Division from any liability or responsibility for any misuse of
the authority or misappropriation of any funds on the part of my appointed Authorized Agent. I understand that changes in the Authorized Agent’s
powers or revocation of an Agent’s authority shall be in writing, either notarized or signed in the presence of ADG - Racing Division employee, and
shall be filed with the Department of Gaming and the Horsemen’s Bookkeeper.
______________________________________________
______________________________________
_____________________
SIGNATURE MUST BE NOTARIZED UNLESS SIGNED IN THE
SIGNATURE OF ADG – RACING DIVISION EMPLOYEE
DATE
PRESENCE OF AN EMPLOYEE OF ADG- RACING DIVISION
STATE OF _____________________)
)
County of _____________________)
Subscribed and Sworn before me this ______ day of ____________________, 20 _______.
_____________________________________
My commission expires: __________________________
NOTARY PUBLIC
ADR 205 Revised 6/2016
ARIZONA DEPARTMENT OF GAMING - RACING DIVISION 1110 W. Washington, Suite 450 Phoenix, AZ 85007 Telephone (602) 364-1700
FOR RACING DIVISION USE ONLY
Applicant ID#__________________ Issue Date: __________________
Expiration Date: _______________
AUTHORIZED AGENT APPOINTMENT
A
A
A
MAY NOT
A
A
N APPOINTMENT OF AN
UTHORIZED
GENT FOR ONE CATEGORY OF ACCOUNT
BE UTILIZED TO FORM AN
UTHORIZED
GENT FOR ANY OTHER
.
A
A
MUST
.
ACCOUNT
A SEPARATE
UTHORIZED
GENT FORM
BE SIGNED BY ALL PRINCIPALS FOR EACH SEPARATE AND DISTINCT ACCOUNT
Name of Agent to be Appointed: _______________________________________
License #: ____________________
Please Print
Authorized Agent for:
Individual Owner
Multiple Owners
Corporation
Stable Name __________________________________
Print Stable Name
Name of Principal: ___________________________________________________
License # ____________________
Please Print
Authorized Agent May:
Yes Conduct ALL matters relating to my racing animals, with NO limitations or restrictions
If LIMITATIONS/RESTRICTIONS pertain to this appointment, complete the following:
(All statements A-F must be answered)
A.
Claim horses in my/our name
Yes
No
B.
Sell, buy, or transfer horses without written consent
Yes
No
C.
Receive and endorse checks made payable to me/us
Yes
No
D.
Direct the transfer of money in my/our account
Yes
No
E.
Have checks made payable to himself/herself from my/our account
Yes
No
F.
Other business
-
Yes
No
Describe other business indicating limitations or restrictions, if any: ______________________________
I hereby appoint the person indicted above to act for me on matters relating to my race animals in accordance with Arizona Racing Commission
Rules. I assume full financial responsibility for the acts of my Authorized Agent in connection with this appointment. In granting this authority, I
release the Arizona Racing Commission and the Arizona Department of Gaming/Racing Division from any liability or responsibility for any misuse of
the authority or misappropriation of any funds on the part of my appointed Authorized Agent. I understand that changes in the Authorized Agent’s
powers or revocation of an Agent’s authority shall be in writing, either notarized or signed in the presence of ADG - Racing Division employee, and
shall be filed with the Department of Gaming and the Horsemen’s Bookkeeper.
______________________________________________
______________________________________
_____________________
SIGNATURE MUST BE NOTARIZED UNLESS SIGNED IN THE
SIGNATURE OF ADG – RACING DIVISION EMPLOYEE
DATE
PRESENCE OF AN EMPLOYEE OF ADG- RACING DIVISION
STATE OF _____________________)
)
County of _____________________)
Subscribed and Sworn before me this ______ day of ____________________, 20 _______.
_____________________________________
My commission expires: __________________________
NOTARY PUBLIC
ADR 205 Revised 6/2016