Form OSRC1000 "Ohio State Racing Commission License Application - Eldorado Scioto Downs" - Ohio

What Is Form OSRC1000?

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

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Ohio State Racing Commission;
  • 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 printable version of Form OSRC1000 by clicking the link below or browse more documents and templates provided by the Ohio State Racing Commission.

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Download Form OSRC1000 "Ohio State Racing Commission License Application - Eldorado Scioto Downs" - Ohio

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STEWARDS OR JUDGES APPROVED
LICENSE NUMBER
Eldorado Scioto Downs
P.O. Box 07823
Columbus, Oh 43207
YEAR FINGERPRINTED IN OHIO
INSPECTOR
DATE ISSUED
RECAP NUMBER
ATTN: OSRC
614-295-4670
FINGERPRINTS ARE VALID FIVE (5) YEARS INCLUDING
Fax: 614-295-8876
YEAR PRINTED IN OHIO.
Ohio State Racing Commission License Application for _________
PLEASE PRINT CLEARLY
In accordance with commission rules and regulations, I hereby apply for the following License:
Thoroughbred
Harness
Quarter Horse
Fair
TYPE OF LICENSE
LICENSE FEE
CHECK OR MONEY ORDER #
EMAIL ADDRESS
LAST NAME
FIRST NAME
MI
SOCIAL SECURITY NUMBER
PERMANENT ADDRESS: NUMBER AND STREET
CITY
STATE
ZIP
PRESENT ADDRESS: NUMBER AND STREET
CITY
STATE
ZIP
DATE OF BIRTH (MM/DD/YYYY)
PHONE NUMBER
Other than traffic related, have you been arrested for, or convicted of any criminal charge? If YES, provide all information concerning the
YES
NO
charge or charges, including date, location and final disposition. Attach additional sheets if necessary.
OWNERS
LIST YOUR TRAINER(S) HERE
NAME OF HORSE
LIST OWNER(S)/STABLE NAMES
STEWARDS OR JUDGES APPROVED
LICENSE NUMBER
Eldorado Scioto Downs
P.O. Box 07823
Columbus, Oh 43207
YEAR FINGERPRINTED IN OHIO
INSPECTOR
DATE ISSUED
RECAP NUMBER
ATTN: OSRC
614-295-4670
FINGERPRINTS ARE VALID FIVE (5) YEARS INCLUDING
Fax: 614-295-8876
YEAR PRINTED IN OHIO.
Ohio State Racing Commission License Application for _________
PLEASE PRINT CLEARLY
In accordance with commission rules and regulations, I hereby apply for the following License:
Thoroughbred
Harness
Quarter Horse
Fair
TYPE OF LICENSE
LICENSE FEE
CHECK OR MONEY ORDER #
EMAIL ADDRESS
LAST NAME
FIRST NAME
MI
SOCIAL SECURITY NUMBER
PERMANENT ADDRESS: NUMBER AND STREET
CITY
STATE
ZIP
PRESENT ADDRESS: NUMBER AND STREET
CITY
STATE
ZIP
DATE OF BIRTH (MM/DD/YYYY)
PHONE NUMBER
Other than traffic related, have you been arrested for, or convicted of any criminal charge? If YES, provide all information concerning the
YES
NO
charge or charges, including date, location and final disposition. Attach additional sheets if necessary.
OWNERS
LIST YOUR TRAINER(S) HERE
NAME OF HORSE
LIST OWNER(S)/STABLE NAMES
ALL APPLICANTS
At this time are you under suspension, or ineligible to participate in racing/gaming by any racing/gaming organization, association,
YES
NO
commission or recognized authority in the United States or elsewhere? If YES, state when, where and by whom the rulings were made and
the offense(s) charged. Attach additional sheets if necessary.
Within the past five years has your racing license been denied, suspended or revoked, or have you been ruled ineligible for licensing by
YES
NO
any racing commission or other racing authority? If yes, provide particulars. Attach additional sheets if necessary.
Has racetrack management ever ejected or denied you from admittance to the grounds? If YES, provide details.
YES
NO
Attach additional sheets if necessary.
AUTHORIZED AGENT
To be answered for an authorized or jockey agent license by the person or persons (owner, jockey, etc.) appointing the authorized agent.
I HEREBY APPOINT (NAME):
ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP CODE
To act as my authorized agent/jockey agent for the year written in at the right in all matters pertaining to the racing of my horse
YEAR
under the rules, regulations and conditions of the state racing commission and the laws of the state. I do hereby authorize my said
agent to act for me subject to the following limitations
PRINT NAME OF APPOINTER
STATE LIMITATIONS, IF ANY
It is hereby understood that I assume responsibility for the acts of my authorized agent or jockey agent in connection with this authority.
SIGNATURE OF APPOINTER
This
Day of
, 20
APPRENTICE JOCKEYS ONLY
Name of stable with which you have had one year of previous service:
STABLE NAME
OWNER OF STABLE
NUMBER OF WINNERS RIDDEN
DATE OF FIRST WIN
LOCATION OF FIRST WIN (RACETRACK)
GROOM APPLICATION MUST BE SIGNED BY EMPLOYER
DATE
PRINT NAME OF EMPLOYER
SIGNATURE OF EMPLOYER
YES
NO
ALL APPLICANTS FOR OWNERS AND/OR TRAINERS LICENSES MUST ANSWER THE FOL-
IF YOU DO NOT CARRY WORKERS COMPEN-
NO EMPLOYEES
LOWING: DO YOU CARRY WORKERS COMPENSATION INSURANCE COVERAGE FOR ALL
SATION INSURANCE CHECK THE PROPER
PERSONS YOU EMPLOY?
REASON:
CONTRACT LABOR
READ BEFORE SIGNING
In affixing my signature to this application, I certify I have read and, to the best of my knowledge, correctly and truthfully answered each of the questions or statements on
this application and I agree to follow the rules of the Ohio State Racing Commission. I hereby consent to the search of my person, my personal effects and places that I have
the right to occupy and have control over while on the premises of a permit holder. I agree to provide a breath or urine sample in accordance with the Ohio Rules of Racing. I
consent to the seizure of any illegal article or substance forbidden by the Ohio Rules of Racing found in my possession or in a location under my control on the premises of a
permit holder. My refusal to consent to any searches and seizures described above may result in the immediate revocation of my commission license and my being ruled off
all jursidictions underthe Ohio State Racing Commission.
DATE OF APPLICATION
PRINTED NAME OF APPLICANT
SIGNATURE OF APPLICANT
OSRC 1000 (12/20)
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