Multi Jurisdiction License Form – Fill Out and Use This PDF

Welcome to the RCI Multi-Jurisdiction Licensing Program!

As a racehorse or greyhound owner who may wish to participate in several different racing jurisdictions, you are eligible to apply for multi-jurisdiction license privileges through the RCI Multi-Jurisdiction Licensing Program.

This form is only for those owners who will not be applying for any other type of license (ie, trainer, driver, etc.) If you will be applying for another type of license, please contact those jurisdictions for an application. Some racing commissions may require additional information from you. If so, you will be contacted by that commission and requested to submit addendums to this form.

Please refer to the last page of this form for instructions, list of participating jurisdictions and fee schedule.

1. Applicant Name

If married, full name of spouse, including maiden name:

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13. Give the following information relative to your current employer. If self-employed, so indicate:

Questions 15 - 18 MUST be answered "yes" or "no". Give details in space provided.

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17. Are there any outstanding court-imposed civil judgements against you? If so, attach an explanation. Yes No

21.Statement of Ownership (including questions 22 & 23)

List only horses or greyhounds that you plan to race this year owned wholly or in part by you or leased to you. If leased, or in partnership, so designate.

If additional space is needed in relation to any of the questions above, please use a separate sheet of paper and submit it with this form.

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22.If you listed a Stable Name, or a Corporation Name or any other legal entity as owner of a horse or greyhound underStatementofOwnership(seeQuestion21),pleasetellusabouttheindividualpersonsunderthatnameholding any interest in those horses or greyhounds. Please check with each state you plan on racing in to determine if they require a separate Stable Name registration form be filed, in addition to this application.

24. Are you obligated to have worker's compensation insurance covering employees in connection with racing? If yes, indicate the following:

* (A copy of your worker's compensation certificate of insurance must be attached and submitted with this application.)

25. Are you a New York State public employee, elected public official, political party officer, or police officer?

Inmakingthisapplicationforalicensetoparticipateinracing,itisunderstoodthataninvestigativereportmaybemadewherebyinformation isobtainedthroughpersonalinterviewswiththirdparties,suchasfamilymembers,businessassociates,financialsources,friends,neighbors, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, which may be applicable. Youhavetherighttomakeawrittenrequestwithinareasonableperiodoftimeforacompleteandaccuratedisclosureofadditionalinformation concerning the nature and scope of the investigation.

Bysubmittingthisapplication,I,theundersigned,dohereby(1)agreetoabidebytherulesandregulationsofthepari-mutuelregulatoryagency, the laws of the United States of America, Canada, state/provincial government, municipalities and other subdivisions thereof; and (2) agree to abide by any provisions regarding search and seizure which may be contained in any of the above-mentioned laws, rules and regulations, and I consent and waive any right I have to object to the search, within the grounds of a racetrack or racing association, of any premises or vehicle which I may occupy or control or have the right to occupy or control and of my person, property and effects and the seizure of any article the having of which may be forbidden.

Iunderstandthatparticipationinracingisaprivilege,notaright,thatanylicenseissuedpursuanttothisformissubjecttoconditionsprecedent assetoutintheRulesofRacing,andthatmyfailuretocomplytherewithshallbegroundsforimmediatevoidanceorrevocationofsuchlicense. By acceptance of said license, I agree to abide by the 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 authorized regulatory agency.

Ihereby certify that, under the penalty of perjury, I have read the foregoing form and affirm that every statement contained therein is true and correctly set forth. I do hereby agree that my license may be removed at any time for misstatements or omissions in the foregoing form. I also agree to abide by and obey the rules and regulations and conditions of the authorized regulatory agency in the jurisdictions in which I am granted a license.

Iexpresslyagreetobesubjecttothesubpoenapowersoftheauthorizedregulatoryagencyorawrittenrequestissuedinlieuofasubpoena and to provide the agency with any and all such information or documents which it may so request. This agreement shall extend to anything which relates to any matter which is the subject of an agency hearing or investigation.

Illinois Applicants: The Illinois Racing Board may refuse to issue or may suspend the occupation license of any person who fails to file a return, or to pay the tax, penalty or interest, as required by any tax Act administered by the Illinois Department of Revenue until such time as the requirements of any such tax Act are satisified.

New York Applicants: The authority to request personal information from you, including numbers such as Federal social security and Federal employer identification numbers, and the authority to maintain such information is found in Section 5 of the New York Tax Law. Disclosure of this information by you is mandatory. The principal purpose for which the information is collected is to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns or who may have understated their tax liabilities and to generally identify persons affected by the taxes administered by the Commissioner of Taxation and Finance. The information will be used for identification and licensing purposes and for any other purpose authorized by the New York State Racing and Wagering Board which may include use in a multi-state licensing database. An investigative consumer report may be requested in connection with this application. Your signature authorizes the Racing and Wagering Board to obtain such a report. You may ask in writing whether or not a report was requested and the name and address of the consumer reporting agency used.

If additional space is required for any of the above questions, please use a separate sheet of paper and submit

Instructions for the RCI Multi-State Program

GENERAL INFORMATION. All race jurisdictions listed within the fee structure on the next page accept this license application form. For RCI fingerprintcards or additional information, contact RCI headquarters at (859) 224-7070 or visit www.arci.com. APPLICATIONS. Before signing, make a copy of this completed application form for each jurisdiction you’ll race in, then sign each copy with your original signature. Deliver or mail one signed copy and the applicable fee(s) to each jurisdiction where you seek an owner's license. You must send the application and applicable fees to each one; jurisdictions will not forward copies for you. FINGERPRINTS. SomeStatesrequirefirst-timelicenseestosubmitafingerprint card and an extra fee of $36. If you use an RCI fingerprint card, you only have to submit one fingerprint card to one listed jurisdiction. To have your fingerprint reports sent to the others, where you plan to race, mark those jurisdictions (up to nine) on the back of the RCI fingerprint card. You can be fingerprinted at a racetrack or by the local police or sheriff (bring an RCI fingerprint card with you; most racetracks have a supply). Renewinglicensees might be fingerprinted periodically, and will be advised by each jurisdiction. FEES. Participating jurisdictions’ licensing fees are listed on the next page, with directions to help you properly make out your check(s). WHERE TO MAIL. Completed fingerprints and a check or money order (no cash) may be mailed to the racing commission that requires your prints or where you plan next to race. A signed copy of this application and applicable license fee must accompany the completed fingerprint card and fee (for which a separate check may be required). Refer to the fee list schedule to calculate your fees. For RCI fingerprint cards and for further information you can contact RCI at (859) 224-7070 or www.arci.com.

* Use as a FLORIDA Application Requires the Applicant's signature to be Notorized.

NRC Multi Interactive App 6-12-09