"Application for Horse Racing Licence and Registration" - British Columbia, Canada

The British Columbia Ministry of Tourism, Arts and Culture has released this version of the "Application for Horse Racing Licence and Registration" on June 15, 2016.

This form may be used by all British Columbia residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Application for Horse Racing
Licence and Registration
Gaming Policy and Enforcement Branch – Racing Division
Hastings Racecourse
Fraser Downs Raceway
Mail/Courier: #408-4603 Kingsway, Burnaby, BC V5H 4M4
Telephone: (604) 660-9090
Telephone: (604) 576-3727
Telephone: (604) 660-7407
Fax: (604) 660-7414
Fax: (604) 775-1752
Fax: (604) 576-7910
Web:
www.gaming.gov.bc.ca
BEFORE YOU START
Use this form to apply for a licence to work in the horse racing industry in British Columbia.
Applications must include a non-refundable application fee of $30 (cash, money order, or cheque payable to the “Minister of Finance”).
Applications must include copies of two pieces of personal identification, including one piece of picture identification.
Applications must be completed in full; signature is required in Section 5.
SECTION 1 – APPLICANT INFORMATION
PLEASE PRINT CLEARLY
Surname: (current legal surname)
First name: (legal first name)
Middle name(s): (legal middle names)
Licence type:
Racetrack name:
Medical number: (if you are a rider / driver)
Advised: (signature of judge / steward)
X
Previous licence type:
Previous racetrack name:
Year of previous licence:
Address: (current address) Unit and Street
City
Province
Postal Code
Home phone number: (XXX) XXX-XXXX
Work phone number: (XXX) XXX-XXXX
Email or Text (SMS):
Date of birth: (YYYY-MM-DD)
Gender:
City of birth:
Country of birth:
M
F
Are you a Canadian citizen:
Immigration status: (i.e. visitor, working visa, landed immigrant, etc.)
If NO, you must supply landed immigrant or
Yes
No
work permit documents.
Spouse’s full name: (surname, first name, middle names)
Social Insurance Number:
Married:
Yes
No
Former surnames, legal name changes, or any nicknames: (attach a separate sheet if more space is required)
Surname:
First name:
Middle name:
Date: (YYYY-MM-DD)
Places of residence for the last five years: (city and province/state only – attach a separate sheet if more space is required)
City:
Province/State:
City:
Province/State:
GAMING POLICY AND ENFORCEMENT BRANCH USE ONLY
Expiry date:
New/renewal:
Occupational season:
Licence #:
Location of issue:
Receipt #:
Date:
(T)BRED or (S)BRED:
GBC ID #:
Application #:
Keep your personal information safe. Your completed electronic or paper copy of this form
June 15, 2016
should be stored in a safe and secure place, or destroyed in a secure manner.
Page 1 of 4
Save Form
Print Form
Clear Form
Application for Horse Racing
Licence and Registration
Gaming Policy and Enforcement Branch – Racing Division
Hastings Racecourse
Fraser Downs Raceway
Mail/Courier: #408-4603 Kingsway, Burnaby, BC V5H 4M4
Telephone: (604) 660-9090
Telephone: (604) 576-3727
Telephone: (604) 660-7407
Fax: (604) 660-7414
Fax: (604) 775-1752
Fax: (604) 576-7910
Web:
www.gaming.gov.bc.ca
BEFORE YOU START
Use this form to apply for a licence to work in the horse racing industry in British Columbia.
Applications must include a non-refundable application fee of $30 (cash, money order, or cheque payable to the “Minister of Finance”).
Applications must include copies of two pieces of personal identification, including one piece of picture identification.
Applications must be completed in full; signature is required in Section 5.
SECTION 1 – APPLICANT INFORMATION
PLEASE PRINT CLEARLY
Surname: (current legal surname)
First name: (legal first name)
Middle name(s): (legal middle names)
Licence type:
Racetrack name:
Medical number: (if you are a rider / driver)
Advised: (signature of judge / steward)
X
Previous licence type:
Previous racetrack name:
Year of previous licence:
Address: (current address) Unit and Street
City
Province
Postal Code
Home phone number: (XXX) XXX-XXXX
Work phone number: (XXX) XXX-XXXX
Email or Text (SMS):
Date of birth: (YYYY-MM-DD)
Gender:
City of birth:
Country of birth:
M
F
Are you a Canadian citizen:
Immigration status: (i.e. visitor, working visa, landed immigrant, etc.)
If NO, you must supply landed immigrant or
Yes
No
work permit documents.
Spouse’s full name: (surname, first name, middle names)
Social Insurance Number:
Married:
Yes
No
Former surnames, legal name changes, or any nicknames: (attach a separate sheet if more space is required)
Surname:
First name:
Middle name:
Date: (YYYY-MM-DD)
Places of residence for the last five years: (city and province/state only – attach a separate sheet if more space is required)
City:
Province/State:
City:
Province/State:
GAMING POLICY AND ENFORCEMENT BRANCH USE ONLY
Expiry date:
New/renewal:
Occupational season:
Licence #:
Location of issue:
Receipt #:
Date:
(T)BRED or (S)BRED:
GBC ID #:
Application #:
Keep your personal information safe. Your completed electronic or paper copy of this form
June 15, 2016
should be stored in a safe and secure place, or destroyed in a secure manner.
Page 1 of 4
Gaming Policy and Enforcement Branch
Application for Horse Racing Licence and Registration
SECTION 2 – DETAILS OF LICENSEE AUTHORIZATIONS
Authorized agent(s) name(s):
Trainer(s) name(s):
Jockey’s agent(s) name(s):
SECTION 3 – TRAINED OR OWNED HORSES ON FILE WITH THE RACING SECRETARY
Trained or owned horses: (list horses on file with the Racing Secretary)
Name of horse:
Name of owner / partnership / stable / company:
SECTION 4 – DISCLOSURE
Full disclosure of all incidents and offences is required, including Young Offender information pursuant to Section 119(1)(o) of the Youth Criminal Justice
Act. Failure to fully disclose all incidents and offences is deemed sufficient grounds to deny your application.
1. Have you in the last 10 years,
Arrested
Yes
No
in any jurisdiction, been:
Stopped or Detained (such as for shoplifting or impaired driving)
Yes
No
Charged with any criminal offence, whether found guilty or not
Yes
No
Diverted or received Alternate Justice (such as for theft, shoplifting)
Yes
No
Convicted of any criminal offence, regardless of the sentence
Yes
No
Investigated by police, loss prevention or other authority for any criminal offence
Yes
No
Cases: (complete this section if you answered YES to any of the above – provide details as indicated below – list all cases without exception including
those in which you were not charged or convicted – attach a separate sheet if more space is required)
Date of Arrest / Detention:
Location:
(YYYY-MM-DD)
Age:
Charge / Claim:
(City, Prov / State)
Disposition:
Arresting Agency:
2. Have you, in any racing jurisdiction, been denied any licence or had any licence revoked?
Yes
No
3. Have you, in any racing jurisdiction, had any fines or suspensions?
Yes
No
4. Have you ever had a judgement against you in a civil action?
Yes
No
5. Have you declared bankruptcy or received assistance from a regulatory body or a court because of an outstanding debt?
Yes
No
If you answered YES to any of questions 2-5 above, provide details below: (attach a separate sheet if more space is required)
Keep your personal information safe. Your completed electronic or paper copy of this form
June 15, 2016
should be stored in a safe and secure place, or destroyed in a secure manner.
Page 2 of 4
Gaming Policy and Enforcement Branch
Application for Horse Racing Licence and Registration
SECTION 5 – CONSENT TO RELEASE PERSONAL INFORMATION AND CERTIFICATION
NOTE: Applicants must provide their signature in the space provided below to indicate they understand and agree to the following.
Consent to Release Personal Information (signature required below)
Background Checks and Release of Personal Information
I hereby authorize:
Background checks will include but are not limited to credit history, criminal
record and local indices checks. The Canadian Police Information Centre
1. The Gaming Policy and Enforcement Branch (GPEB) to investigate my
(CPIC) database records will be queried for the disposition of all charges for
suitability for Registration in the gaming industry pursuant to Part 7 and 8
which a person has been fingerprinted (Criminal Record) and all outstanding
of the Gaming Control Act and Gaming Control Regulation. I understand
charges currently before the courts. Local indices checks will be conducted
that GPEB is required to protect the confidentiality and privacy of personal
through the RCMP PIRS, PROS, PRIME and LEIP and any other City,
information provided, in accordance with The Freedom of Information and
Municipal, Provincial, Federal, State, County, Sheriffs, FBI or other police
Protection of Privacy Act (British Columbia).
databases in Canada or the USA that GPEB deems appropriate. These
databases record all complaints the respective police departments investigate
2. Any City, Municipal, or Provincial Police department or public body
and include information related to non convictions and charges regardless of
including GPEB, pursuant to Section 33 of the Freedom of Information and
disposition. Therefore full disclosure of all criminal and civil proceedings is
Protection of Privacy Act (British Columbia), and the Royal Canadian
required and each case will be decided on its own merit. If necessary, an
Mounted Police pursuant to Section 8 (1) of the Privacy Act of Canada, to
applicant will be required to provide fingerprints to verify whether or not they
release any and all personal information and records, (including
have a criminal record.
convictions, non convictions and charges regardless of disposition)
retained by them in their files, including PIRS, CPIC, PROS, PRIME and
You must provide GPEB with the written authorization necessary to allow the
LEIP or any other local indices and databases, and necessary for GPEB to
police or other public bodies to release relevant information including
perform registration and enforcement responsibilities under the Gaming
information relating to the Young Offenders Act to GPEB for the purposes of
Control Act.
registration and enforcement of the Gaming Control Act. The information
requested is collected under the authority of the Gaming Control Act [SBC
3. Any Organization pursuant to Section 6 (2) (a) of the Personal
2002].
Information Protection Act (British Columbia), to disclose my personal
information to GPEB in order for GPEB to conduct a background
investigation in accordance with the Gaming Control Act.
4. GPEB and any Police Departments, Public Bodies or Organizations
noted in paragraphs 2 and 3 above to utilize this consent to conduct any
future background checks and/or release any documents necessary to
continue registration or to approve any subsequent applications, including
electronic applications, submitted to renew registration.
5. GPEB to release my personal identification information (name, date of
birth, address and telephone number) to The Association of Racing
Commissioners International (ARCI) for the purpose of recording race
findings within the horse racing industry in North America.
Certification (signature required below)
I certify that all of the information provided by me in this application for a
horse racing licence/registration is true to the best of my knowledge and
belief.
I understand that any false or inaccurate statements made in this application
for horse racing licence / registration, or failure to disclose may be deemed
sufficient cause for rejection of my application by the Gaming Policy and
Enforcement Branch.
I certify that I have read and understand the conditions of registration
included with this application.
Signature of applicant:
Name: (print your full name)
Effective today: (YYYY-MM-DD)
X
GAMING POLICY AND ENFORCEMENT BRANCH USE ONLY
Application complete
Photo
Fee enclosed
Equifax
CPIC
Interpol
PIRS/PRIME __________
PROS/LEIP
JUSTIN
Online Service
Other ______________________
Date:
Investigator:
Approved
Rejected
Keep your personal information safe. Your completed electronic or paper copy of this form
June 15, 2016
should be stored in a safe and secure place, or destroyed in a secure manner.
Page 3 of 4
Gaming Policy and Enforcement Branch
Application for Horse Racing Licence and Registration
SECTION 6 – CONDITIONS OF REGISTRATION
Failure to comply with any of the following conditions may be grounds for the Director of Registration to cancel registration. Registration may
not be transferred to any person.
1.
Compliance required:
A registrant shall comply with:
a)
Applicable legislation;
b)
Lawful policies, orders and directions of the province and its agents;
c)
Conditions set out in this policy or from time to time established by the Director of Registration;
d)
Specific conditions, if any, established by the Director of Registration for the registrant; and
e)
The rules of racing and accept and abide by the rulings and decisions of the stewards / judges, and racing officials.
2.
The Horse Racing Identification Licence must be carried at all times when on the grounds of a horse racing event and must be produced
immediately when requested by an official of the Gaming Policy and Enforcement Branch.
3.
Director of Registration to be notified on certain events:
A registrant must immediately notify the Director of Registration in writing if:
a)
The registrant changes his or her name.
b)
The registrant is under criminal investigation or is charged or has charges pending in relation to a criminal matter.
c)
A civil suit involving allegations of fraud, theft, deceit, misrepresentation or similar conduct is commenced against the registrant.
How the Director of
By Mail:
By Fax:
Registration is Notified
Director of Registration
Victoria (250) 356-0782
P.O. Box 9202 Stn. Prov. Govt
Victoria, BC V8W 9J1
How to Contact the
By Mail:
By Phone or Fax:
Horse Racing Division
Executive Director of Horse Racing
Main Office
Hastings Racecourse
Fraser Downs Raceway
#408-4603 Kingsway Avenue
Tel: (604) 660-7407
Tel: (604) 660-9090
Tel: (604) 576-3727
Burnaby, BC V5H 4M4
Fax: (604) 660-7414
Fax: (604) 775-1752
Fax: (604) 576-7910
Keep your personal information safe. Your completed electronic or paper copy of this form
June 15, 2016
should be stored in a safe and secure place, or destroyed in a secure manner.
Page 4 of 4
British Columbia Ministry of Tourism, Arts and Culture License Application Form Application Form British Columbia Legal Forms Canada Legal Forms

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