Form ADR202 "Application for Business/Vendor License" - Arizona

What Is Form ADR202?

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 ADR202 by clicking the link below or browse more documents and templates provided by the Arizona Department of Gaming - Division of Racing.

ADVERTISEMENT
ADVERTISEMENT

Download Form ADR202 "Application for Business/Vendor License" - Arizona

Download PDF

Fill PDF online

Rate (4.7 / 5) 56 votes
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: _______________
A
F
B
/V
L
PPLICATION
OR
USINESS
ENDOR
ICENSE
Application Date: ________________________
Track: ___________________________________
B
/V
N
:
TYPE OF BUSINESS
S
P
:
USINESS
ENDOR
AME
OR
ERVICES
ERFORMED
B
/V
:
USINESS
ENDOR IS A
(Complete A & D)
PARTNERSHIP (Complete B & D)
SOLE PROPRIETORSHIP (Complete C & D)
CORPORATION
#
#:
FEDERAL TAX ID
OR SS
I
,
A
D
G
– R
T IS STIPULATED AND AGREED THAT ANY NOTICE
CORRESPONDENCE OR PAPERS OF ANY NATURE ADDRESSED TO ME FROM THE
RIZONA
EPARTMENT OF
AMING
ACING
D
:
IVISION ARE TO BE SENT TO THE FOLLOWING ADDRESS
:
BUSINESS ADDRESS
____________________________________________________________________________________
_
S
A
TREET
DDRESS
_
________________________________
__________________ _______________________
_
C
S
ITY
TATE
ZIP
B
P
(_______) _____________________
F
(_________) _______________________
USINESS
HONE
AX
T
/P
APPROVAL OF
RACK
ERMITTEE MANAGEMENT TO CONDUCT BUSINESS ON PERMITTEE GROUNDS
_______________________________________
L
,
: _____________________________________________
IMITATIONS
IF ANY
S
/
IGNATURE OF TRACK
PERMITTEE OFFICIAL
SECTION A - CORPORATION: ATTACH THE FOLLOWING REQUIRED DOCUMENTS
A
I
RTICLES OF
NCORPORATION
L
ALL D
, O
, S
, AND
10%
C
ISTING OF
IRECTORS
FFICERS
HAREHOLDERS
ALL PERSONS WHOSE OWNERSHIP EXCEEDS
OF THE
ORPORATION
O
C
,
,
,
,
RGANIZATIONAL
HART OF CORPORATION
INCLUDING THE PARENT CORPORATION
HOLDING CORPORATION
SUBSIDIARY OF PARENT
/
(
),
/
GENERAL
LIMITED PARTNERSHIPS AND PUBLICLY HELD
INCLUDING STOCK OPTIONS OF FORMER MANAGEMENT EMPLOYEES
AND
OR OTHER PERTINENT
.
OWNERSHIP INTEREST
ADR-201 L
A
D
, O
ICENSE
PPLICATION FULLY EXECUTED FOR
IRECTORS
FFICERS AND OTHER EMPLOYEES OF THE CORPORATION OR SUBSIDIARY THEREOF
/
A
(
)
,
WHO ACTUALLY PROVIDE SERVICES AND
OR MANAGEMENT INVOLVEMENT IN THE ACTIVITIES FOR AN
RIZONA PERMITEE
TRACK
ON A REGULAR BASIS
F
C
,
/F
INGERPRINT
ARD
AND LICENSE
INGERPRINT FEES
========================================================================================================================================
SECTION B -PARTNERSHIP: ATTACH THE FOLLOWING REQUIRED DOCUMENTS
L
EACH
IST
PARTNER AND OWNERSHIP PERCENTAGE BELOW
ADR-201 L
A
F
C
,
/F
ICENSE
PPLICATION FULLY EXECUTED FOR EACH PARTNER
INGERPRINT
ARD
AND LICENSE
INGERPRINT FEES
=================================================================================================
ADR 202 Revised 6/2016
1
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: _______________
A
F
B
/V
L
PPLICATION
OR
USINESS
ENDOR
ICENSE
Application Date: ________________________
Track: ___________________________________
B
/V
N
:
TYPE OF BUSINESS
S
P
:
USINESS
ENDOR
AME
OR
ERVICES
ERFORMED
B
/V
:
USINESS
ENDOR IS A
(Complete A & D)
PARTNERSHIP (Complete B & D)
SOLE PROPRIETORSHIP (Complete C & D)
CORPORATION
#
#:
FEDERAL TAX ID
OR SS
I
,
A
D
G
– R
T IS STIPULATED AND AGREED THAT ANY NOTICE
CORRESPONDENCE OR PAPERS OF ANY NATURE ADDRESSED TO ME FROM THE
RIZONA
EPARTMENT OF
AMING
ACING
D
:
IVISION ARE TO BE SENT TO THE FOLLOWING ADDRESS
:
BUSINESS ADDRESS
____________________________________________________________________________________
_
S
A
TREET
DDRESS
_
________________________________
__________________ _______________________
_
C
S
ITY
TATE
ZIP
B
P
(_______) _____________________
F
(_________) _______________________
USINESS
HONE
AX
T
/P
APPROVAL OF
RACK
ERMITTEE MANAGEMENT TO CONDUCT BUSINESS ON PERMITTEE GROUNDS
_______________________________________
L
,
: _____________________________________________
IMITATIONS
IF ANY
S
/
IGNATURE OF TRACK
PERMITTEE OFFICIAL
SECTION A - CORPORATION: ATTACH THE FOLLOWING REQUIRED DOCUMENTS
A
I
RTICLES OF
NCORPORATION
L
ALL D
, O
, S
, AND
10%
C
ISTING OF
IRECTORS
FFICERS
HAREHOLDERS
ALL PERSONS WHOSE OWNERSHIP EXCEEDS
OF THE
ORPORATION
O
C
,
,
,
,
RGANIZATIONAL
HART OF CORPORATION
INCLUDING THE PARENT CORPORATION
HOLDING CORPORATION
SUBSIDIARY OF PARENT
/
(
),
/
GENERAL
LIMITED PARTNERSHIPS AND PUBLICLY HELD
INCLUDING STOCK OPTIONS OF FORMER MANAGEMENT EMPLOYEES
AND
OR OTHER PERTINENT
.
OWNERSHIP INTEREST
ADR-201 L
A
D
, O
ICENSE
PPLICATION FULLY EXECUTED FOR
IRECTORS
FFICERS AND OTHER EMPLOYEES OF THE CORPORATION OR SUBSIDIARY THEREOF
/
A
(
)
,
WHO ACTUALLY PROVIDE SERVICES AND
OR MANAGEMENT INVOLVEMENT IN THE ACTIVITIES FOR AN
RIZONA PERMITEE
TRACK
ON A REGULAR BASIS
F
C
,
/F
INGERPRINT
ARD
AND LICENSE
INGERPRINT FEES
========================================================================================================================================
SECTION B -PARTNERSHIP: ATTACH THE FOLLOWING REQUIRED DOCUMENTS
L
EACH
IST
PARTNER AND OWNERSHIP PERCENTAGE BELOW
ADR-201 L
A
F
C
,
/F
ICENSE
PPLICATION FULLY EXECUTED FOR EACH PARTNER
INGERPRINT
ARD
AND LICENSE
INGERPRINT FEES
=================================================================================================
ADR 202 Revised 6/2016
1
ARIZONA DEPARTMENT OF GAMING - RACING DIVISION 1110 W. Washington, Suite 450 Phoenix, AZ 85007 Telephone (602) 364-1700
SECTION C –SOLE PROPRIETORSHIP: ATTACH THE FOLLOWING REQUIRED DOCUMENTS
ADR-201 L
A
, F
C
,
/F
ICENSE
PPLICATION FULLY EXECUTED
INGERPRINT
ARD
AND LICENSE
INGERPRINT FEES
===============================================================================================
SECTION D – NAME OF DIRECTOR, OFFICER, STOCKHOLDER OR OWNER
NAME
PERCENTAGE % OWNED
LICENSE NUMBER
(U
A
B
S
N
)
SE
DDITIONAL
LANK
HEETS IF
ECESSARY
A FALSE ANSWER OR INCOMPLETE ANSWER TO ANY QUESTION REQUIRED IN THIS APPLICATION CONSTITUTES GROUNDS FOR
DENIAL, SUSPENSION OR REVOCATION OF YOUR LICENSE
T
A
R
C
.
HE UNDERSIGNED HEREBY MAKES APPLICATION FOR A LICENSE TO BE ISSUED IN ACCORDANCE WITH THE TERMS AND PROVISIONS OF THE RULES OF THE
RIZONA
ACING
OMMISSION
T
. T
HE UNDERSIGNED CERTIFIES THAT ALL THE FOREGOING STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE
HE UNDERSIGNED HAVING READ THE COMPLETE
(
)
APPLICATION UNDERSTANDS THAT THIS LICENSE MAY BE DENIED AND THAT THE APPLICANT
S
MAY BE CHARGED WITH A CRIMINAL OFFENSE FOR KNOWINGLY MAKING ANY FALSE
. T
D
(
)
STATEMENTS OR OMISSIONS ON THIS APPLICATION
HE ISSUANCE OF A LICENSE BY THE
EPARTMENT DOES NOT NECESSARILY ENTITLE THE HOLDER
S
TO ANY RIGHTS OR PRIVILEGES AT
D
. N
D
.
THE PREMISES OF ANY TRACK LICENSED BY THE
EPARTMENT
OTIFICATION TO THE
EPARTMENT FOR CHANGE OF ADDRESS IS THE SOLE RESPONSIBILITY OF THE UNDERSIGNED
S
,
,
,
D
EARCH OF PERSONS
VEHICLES
BUSINESS FACILITY
OR ENCLOSURES MAY BE MADE BY REPRESENTATIVES OF THE
EPARTMENT WHILE ON THE GROUNDS UNDER THE SUPERVISION OF THE
D
. I
,
EPARTMENT
F PAYMENT OF FEES IS MADE BY CHECK AND THAT CHECK IS NOT ON A VALID ACCOUNT OR DRAWN WITHOUT SUFFICIENT FUNDS
THE LICENSE ISSUED SHALL BE NULL AND
$25.00
.
VOID AND AN AUTOMATIC FINE OF
SHALL BE IMPOSED
I C
T
T
S
A
A
I H
M
I
T
A
A
T
A
C
.
ERTIFY
HAT
HE
TATEMENTS
ND
NSWERS
AVE
ADE
N
HIS
PPLICATION
RE
RUE
ND
ORRECT
X_______________________________________________________
Signature of License Applicant
Submit Cash, Credit Card, Cashier’s Check or Money Order in the amount of $500.00, 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
2
ADR 202 Revised 6/2016
Page of 2