Fillable Printable Khrc 009-02-Authorized Agent Form 2

Khrc 009-02-Authorized Agent Form 2

KHRC009‐02(5/10)

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Equal Opportunity M/F/D

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KENTUCKYHORSERACINGCOMMISSION

4063IronworksParkway,BuildingB

Lexington,Kentucky40511

Phone:(859)246‐2040Fax:(859)246‐2039

www.khrc.ky.gov

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AUTHORIZEDAGENTLICENSEAPPLICATION

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THISFORMMUSTBENOTARIZED

MUSTRETURNORIGINALTOKHRC

$25.00annuallicensefee

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_______________________________,20_____

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Pursuantto810KAR1:010,I,_________________________________,havethisdayappointed

__________________________________,SS#__________________________,asmyauthorized agent

toperformthefollowingdutiesortakethefollowingactionsonmybehalf(initialallthatapply):

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IFYOUAREANOWNER:

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______ToactformeinallmatterspertainingtotheracingofmyhorsesundertheRulesofRacingas

adoptedbytheKentuckyHorseRacingCommission,exceptforclaiminghorsesandauthorizing

placementofadvertingorpromotionalmaterials.

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______Toclaimhorsesformyaccountandto

drawmoneyfrommyaccountwiththeHorseman’s

Bookkeeperwithnolimitationsunlessstatedbelow:

_____________________________________________________________________________________

_____________________________________________________________________________________

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______Toauthorizeplacementofadvertisingorpromotionalmaterialspursuantto810KAR1:009

Section15,includingexecutionofthe“RequesttoWearAdvertisingandPromotionalMaterials”form

andthe“Owner/JockeyA dvertisingandPromotional

MaterialsAgreement”withnolimitationsunless

statedbelow:

_____________________________________________________________________________________

_____________________________________________________________________________________

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KHRC009‐02(5/10)

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Equal Opportunity M/F/D

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IFYOUAREAJOCKEY:

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______Toauthorizeplacementofadvertisingorpromotionalmaterialspursuantto810KAR1:009

Section15,includingexecutionofthe“RequesttoWearAdvertisingandPromotionalMaterials”form

andthe“Owner/JockeyA dvertisingandPromotionalMaterialsAgreement”withnolimitationsunless

statedbelow:

_____________________________________________________________________________________

_____________________________________________________________________________________

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EXPIRESDECEMBER31,20____or______________________________,

20____

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_____________________________________________

Signature

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_____________________________________________

PrintedName

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Subscribedandsworntobeforemethis_______dayof__________________intheyear__________.

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_________________________________________

NotaryPublic

MyCommissionExpires:______________________

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IFAGENTisnotcurrentlylicensedinKentuckyinsomeothercapacity(Owner,Trainer,Jockey’sAgent

etc.),pleaseanswerthefollowingquestions(attachadditionalpagesifnecessary):

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Name:_______________________________________________________________________________

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PermanentAddress:____________________________________________________________________

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DateofBirth:_____________________________SocialSecurityNo._______________________

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YearandcapacitypreviouslylicensedinKentucky:____________________________________________

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Currentlylicensedas__________________________________________________________instatesof

_____________________________________________________________________________________

_____________________________________________________________________________________

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Haveyoubeenarrestedorchargedwithacrime,otherthanatrafficviolation,inthelast15years?If

yes,pleaseexplain.____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

KHRC009‐02(5/10)

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Equal Opportunity M/F/D

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Areyoucurrentlyonparoleorprobation?Ifyes,pleaseexplain.________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Haveyoueverbeenfinedover$100byanyracingjurisdiction?Ifyes,pleaseexplain._______________ 

_____________________________________________________________________________________

_____________________________________________________________________________________

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Haveyou,yourspouse,amemberofyourimmediatefamily,orotherpersoninasimilarrelationshipto

you

everhadalicensedenied,revoked,suspended,orisacomplaintpendinginanyjurisdiction?Ifyes,

pleaseexplain.________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Haveyoueverbeenruledoff,ejected,orexcludedfromaracingassociationgrounds?Ifyes,please

explain.______________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Haveyoueverbeenissuedalicense

underanothername(s)?Ifyes,pleaseprovideothernames._____

_____________________________________________________________________________________

_____________________________________________________________________________________

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IunderstandthatparticipationinracinginKentuckyisaprivilege,notaright,thatthelicense

issuedpursuanttothisapplicationissubjecttoconditionsprecedentassetoutintheKentuckyRules

ofRacing,andthatmy

failuretocomplytherewithshallbegroundsforimmediatevoidanceor

revocationofsuchlicense.Byacceptanceofsaidlicense,IagreetoabidebytheKentuckyRulesof

RacingandrulingsordecisionsoftheStewardswiththeknowledgethatrulingsordecisionsofthe

Stewardsshallremainin

forceuntilreversedormodifiedonlybythe KentuckyHorseRacing

Commission.

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IherebycertifythatIhavereadandunderstandtheforegoingandaffirmeverystatement

madebymeinthisapplicationasbeingcompleteandtrue,andintheeventanysuchstatementshall

becomeincorrectoruntrue,

IshallimmediatelynotifytheKentuckyHorseRacingCommissionofsuch

change.

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_____________________________________________

SignatureofAgent