"License Application Form" - Delaware

This Delaware-specific "License Application Form" is a document released by the Delaware Department of Agriculture.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "License Application Form" - Delaware

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LICENSE APPLICATION
MONEY ORDER _______
EXPIRATION DATES
STATE OF DELAWARE
A-D
12-31
HARNESS RACING COMMISSION
CHECK ______________
E-K
3-31
DEPARTMENT OF AGRICULTURE
L-Q
6-30
2320 S. DUPONT HIGHWAY
CASH _______________
R-Z
9-30
DOVER, DELAWARE 19901
For Information (during live racing) call:
CREDIT CARD_________
APPROVED BY:
Dover Downs: 302-674-4600, ask for licensing office
__________________
Harrington Raceway: 302-398-7223, ask for licensing office
FOR YEAR 20______
YEAR & JURISDICTION LAST FINGERPRINTED______________________________________
Please Print
TYPE OF LICENSE
License Fee:
APPLIED FOR:
1. Applicant Name __________________________________________________________________
2. Permanent Address ______________________________________________________________
3. Local Address ___________________________________________________________________
4. Telephone: Home ________________ Cell ____________________ Work ___________________
5. Spouse’s Full Name: ______________________________________________________________
6. Date of Birth ______/______/______
Place of Birth __________________________________
SEX
WEIGHT
HEIGHT
COLOR HAIR
COLOR EYES
OFF-TRACK OCCUP.
SOC. SEC. NUMBER
7.
8. Are you a member of the United States Trotting Association? Member Number: _______________
Expiration Date: _________________
9. Grooms or Assistant Trainers: Name of Employer or Stable: ________________________________
Employer Signature: _________________________________
10. List all Jurisdictions in which you have been licensed in the last 3 years:
Use additional paper if necessary.
JURISDICTION
DATES
TYPE OF LICENSE
Are you currently in good standing in each
of these jurisdictions?
YES________ NO_________
Do you have any complaints (charges)
pending in any of these jurisdictions?
YES_________ NO ________
11. In the last ten years, has your license (or your spouse’s license) been denied, suspended (7 days or
more), disapproved, or revoked or is a complaint pending in any jurisdiction?
YES
NO
If yes,
please provide details.
__________________________________________________________________________________
12. Have you ever been fined $500 or more or been ejected or denied admission to any racetrack by
any racing official or commission? YES
NO
If yes, please provide details:
___________________________________________________________________________________
LICENSE APPLICATION
MONEY ORDER _______
EXPIRATION DATES
STATE OF DELAWARE
A-D
12-31
HARNESS RACING COMMISSION
CHECK ______________
E-K
3-31
DEPARTMENT OF AGRICULTURE
L-Q
6-30
2320 S. DUPONT HIGHWAY
CASH _______________
R-Z
9-30
DOVER, DELAWARE 19901
For Information (during live racing) call:
CREDIT CARD_________
APPROVED BY:
Dover Downs: 302-674-4600, ask for licensing office
__________________
Harrington Raceway: 302-398-7223, ask for licensing office
FOR YEAR 20______
YEAR & JURISDICTION LAST FINGERPRINTED______________________________________
Please Print
TYPE OF LICENSE
License Fee:
APPLIED FOR:
1. Applicant Name __________________________________________________________________
2. Permanent Address ______________________________________________________________
3. Local Address ___________________________________________________________________
4. Telephone: Home ________________ Cell ____________________ Work ___________________
5. Spouse’s Full Name: ______________________________________________________________
6. Date of Birth ______/______/______
Place of Birth __________________________________
SEX
WEIGHT
HEIGHT
COLOR HAIR
COLOR EYES
OFF-TRACK OCCUP.
SOC. SEC. NUMBER
7.
8. Are you a member of the United States Trotting Association? Member Number: _______________
Expiration Date: _________________
9. Grooms or Assistant Trainers: Name of Employer or Stable: ________________________________
Employer Signature: _________________________________
10. List all Jurisdictions in which you have been licensed in the last 3 years:
Use additional paper if necessary.
JURISDICTION
DATES
TYPE OF LICENSE
Are you currently in good standing in each
of these jurisdictions?
YES________ NO_________
Do you have any complaints (charges)
pending in any of these jurisdictions?
YES_________ NO ________
11. In the last ten years, has your license (or your spouse’s license) been denied, suspended (7 days or
more), disapproved, or revoked or is a complaint pending in any jurisdiction?
YES
NO
If yes,
please provide details.
__________________________________________________________________________________
12. Have you ever been fined $500 or more or been ejected or denied admission to any racetrack by
any racing official or commission? YES
NO
If yes, please provide details:
___________________________________________________________________________________
13. IN THE LAST TEN YEARS HAVE YOU BEEN ARRESTED OR CONVICTED OR SERVED TIME
ON ANY CRIMINAL CHARGE OR SERIOUS TRAFFIC OFFENSE, INCLUDING DUI? IF SO,
PROVIDE ALL INFORMATION CONCERNING THE CHARGE(S), INCLUDING DATE, LOCATION,
AND FINAL DISPOSITION. (All arrests must be reported whether dismissed or whether you were
convicted or received a suspended sentence.)
___________________________________________________________________________________
___________________________________________________________________________________
14. Are there now any indictments or complaints pending against you (or your spouse) for any public
offense or are you currently on parole or probation? YES
NO
If yes, please provide details:
___________________________________________________________________________________
15. Have you ever been involved in bookmaking or other illegal gambling or associated with anyone so
involved?
YES
NO
If yes, please attach particulars
___________________________________________________________________________________
16. Do you have or will you have employees working for you on the track? If yes, you are required by the
Delaware Workmen’s Compensation Act to secure current insurance to provide for compensation of all
such employees. YES
NO
List Company:_______________________________________
17. Please list all horses you currently own or lease and provide the trainer, complete ownership of each
horse, and where each horse is stabled. Attach additional sheet if necessary.
HORSE
OWNER(S)
TRAINER
LOCATION
18. If you are under 18 years of age, working papers or education certificate must be submitted with this
application. Fill in the following:
_______________________________________________________________________________
School District
Certificate Number
ANY PERSONS MAKING ANY FALSE, UNTRUE, OR MISLEADING STATEMENT ON AN APPLICATION FOR A
LICENSE MAY BE DENIED A LICENSE OR MAY BE SUSPENDED &/OR FINED OR HAVE LICENSE REVOKED.
I hereby certify that I am not under suspension or in bad standing with any racing jurisdiction and that I
have read the application and know its contents and that every statement contained herein is true and
correct.
____________________________
_____________________________________
Signature of Applicant
Signature of Parent or Legal Guardian indicating
Acceptance of full responsibility for this applicant for
For license when applicant is under 18 years of age.
A person younger than 14 years of age may apply for an owner’s license, however; no licensed owner younger than 14 years of age will be permitted in the paddock. If younger than 18 years
of age, an applicant shall submit a notarized affidavit from his/her parents or legal guardian stating that the parent or legal guardian expressly assumes responsibility for the applicant’s
financial, contractual, and other obligations relating to the applicant’s participation in racing.
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