Form ADR220 "Application for Duplicate License" - Arizona

Form ADR220 is a Arizona Department of Gaming - Division of Racing form also known as the "Application For Duplicate License". The latest edition of the form was released in January 1, 2017 and is available for digital filing.

Download a PDF version of the Form ADR220 down below or find it on Arizona Department of Gaming - Division of Racing Forms website.

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Download Form ADR220 "Application for Duplicate License" - 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#__________________ Original Issue Date: __________________
Expiration Date: _______________
Date Duplicate License Issued: ____________________
APPLICATION FOR DUPLICATE LICENSE
Application Date: ______________________
Track: ________________________________
NAME
DOB
SS#
PREVIOUS NAME
STREET ADDRESS
CITY
STATE/ZIP
HOME PHONE#
CELL PHONE#
I REQUIRE THIS DUPLICATE LICENSE FOR THE FOLLOWING REASON: _____________________________________________
______________________________________________________________________________________________________
1.
Since you last filed an application with the ADG, RACING DIVISION, have you been arrested, detained, charged, had any
indictments, citations or summons to answer for any criminal offense or violation for any reason whatsoever (except
minor traffic violations), regardless of the disposition of the event, dismissals, expunged/sealed or restoration of civil
rights?
______YES
______NO
(If YES, provide detailed explanation on page 2).
2.
Since you last filed an application with the ADG, RACING DIVISION, has your racing license been denied, suspended, or
revoked or have you had any fines issued from any racing jurisdiction, including Arizona?
_______YES
______NO
(If YES, provide detailed explanation on page 2).
A.R.S. §25-320 MANDATES
MUST
THAT EACH LICENSING BOARD OR AGENCY THAT ISSUES PROFESSIONAL OR OCCUPATIONAL LICENSES OR CERTIFICATES
. T
,
OBTAIN AND RECORD THE SOCIAL SECURITY NUMBER OF AN APPLICANT FOR PROFESSIONAL OR OCCUPATIONAL LICENSE OR CERTIFICATE
HEREFORE
IT IS
MANDATORY
. W
,
THAT YOUR SOCIAL SECURITY NUMBER IS PROVIDED ON THIS APPLICATION
HEN SOCIAL SECURITY NUMBERS APPEAR ON PUBLIC RECORDS
,
MUST
.
AND COPIES OF SUCH RECORDS BECOME THE SUBJECT OF A RECORDS REQUEST
SOCIAL SECURITY NUMBERS
BE REDACTED FROM THE DOCUMENT
____________________________________
__________________________________
S
A
E
– ADG R
IGNATURE OF
PPLICANT
MPLOYEE
ACING DIVISION
1
ADR 220 Revised 1/2017
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#__________________ Original Issue Date: __________________
Expiration Date: _______________
Date Duplicate License Issued: ____________________
APPLICATION FOR DUPLICATE LICENSE
Application Date: ______________________
Track: ________________________________
NAME
DOB
SS#
PREVIOUS NAME
STREET ADDRESS
CITY
STATE/ZIP
HOME PHONE#
CELL PHONE#
I REQUIRE THIS DUPLICATE LICENSE FOR THE FOLLOWING REASON: _____________________________________________
______________________________________________________________________________________________________
1.
Since you last filed an application with the ADG, RACING DIVISION, have you been arrested, detained, charged, had any
indictments, citations or summons to answer for any criminal offense or violation for any reason whatsoever (except
minor traffic violations), regardless of the disposition of the event, dismissals, expunged/sealed or restoration of civil
rights?
______YES
______NO
(If YES, provide detailed explanation on page 2).
2.
Since you last filed an application with the ADG, RACING DIVISION, has your racing license been denied, suspended, or
revoked or have you had any fines issued from any racing jurisdiction, including Arizona?
_______YES
______NO
(If YES, provide detailed explanation on page 2).
A.R.S. §25-320 MANDATES
MUST
THAT EACH LICENSING BOARD OR AGENCY THAT ISSUES PROFESSIONAL OR OCCUPATIONAL LICENSES OR CERTIFICATES
. T
,
OBTAIN AND RECORD THE SOCIAL SECURITY NUMBER OF AN APPLICANT FOR PROFESSIONAL OR OCCUPATIONAL LICENSE OR CERTIFICATE
HEREFORE
IT IS
MANDATORY
. W
,
THAT YOUR SOCIAL SECURITY NUMBER IS PROVIDED ON THIS APPLICATION
HEN SOCIAL SECURITY NUMBERS APPEAR ON PUBLIC RECORDS
,
MUST
.
AND COPIES OF SUCH RECORDS BECOME THE SUBJECT OF A RECORDS REQUEST
SOCIAL SECURITY NUMBERS
BE REDACTED FROM THE DOCUMENT
____________________________________
__________________________________
S
A
E
– ADG R
IGNATURE OF
PPLICANT
MPLOYEE
ACING DIVISION
1
ADR 220 Revised 1/2017
ARIZONA DEPARTMENT OF GAMING - RACING DIVISION 1110 W. Washington, Suite 450 Phoenix, AZ 85007 Telephone (602) 364-1700
If you answered 'Yes' to any question, you must provide a full explanation of the circumstances. [For example,
provide dates, city, state, nature of offense or violation, name of court involved, disposition (i.e. fine, confinement,
etc.), and reason for license suspension, denial, or fines. Use additional sheets if necessary.
__________________________________________________________________________________________
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__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Submit cash, credit card, cashier’s check or money order in the amount of $7.00, payable to the Arizona Department of
Gaming. (Personal Checks will not be accepted.)
Payment Type:
Cash
Cashier’s Check #___________________
Money Order # _____________________
Credit Card
Authorization #________________________ Receipt # ____________________________
LICENSING
INVESTIGATOR
BOARD OF STEWARDS
__________ APPROVED
___________ PROCESSED
_____________ REVIEWED
__________APPROVED WITH CONDITIONS
_____________ INTERVIEWED
__________ DENIED
ADR 220 Revised 1/2017
2
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