Online Application :: Nebraska Racing Commission

LICENSE FEES

1. Check one

17 Admissions Employee*

21 Concession Employee*

22 Food/Bev Employee*

24 Groom or Hotwalker*

33 Security Guard*

37 Assistant Starter*

38 Mutuel Employee*

45 Jockey Agent (per rider)*

41 Veterinary Assistant

51 Exercise Rider

52 Official

53 Outrider*

54 Owner

55 Plater

56 Pony Person

57 Valet*

$40 Fees

58 Assistant Trainer*

59 Stable Foreman*

60 Trainer

* Employer's Signature Required

65 Jockey

61 Apprentice Jockey

66 Owner/Trainer Combination

OtherLicense

Fee:

APPLICANT INFORMATION

2.Full Name *

3.HomeTelephone

BusinessPhone

PERMANENT ADDRESS

Street *

City *

State *

Zipcode *

Hair *

Eyes *

Email Address *

Confirm Email Address *

4.SocialSecurity *

5.Date of Birth *

8. City and State of Birth *

Sex *

Male

Female

Height *

Weight *

Citizenship *

7. For the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114, I attest as follows:

I am a citizen of the United States *

yes

no

I am a qualified alien under the Federal Immigration and Nationality Act. *

Yes.

No

my_immigration_status_and_alien_number_as_ follows: *

I hereby agree to provide a copy of my USCIS documentation upon request.

I hereby attest that my response and the information provided on this form and any related application for public benefits are true, complete and accurate and I understand that this information may be used to verify my lawful presence in the United States

9. EMERGENCY CONTACT

Emergency Name *

Emergency Address *

Emergency Phone *

10. VEHICLES

Vehicle 1 Year and Make *

Vehicle 1 License/State *

Vehicle 2 Year and Make

Vehicle 2 License/State

Marital Status

Married

Single

12. Spouse's Name *

13. Maiden Name

14. PRIOR RACING LICENSES

First Prior License

1. Type

1. State

1. Year

Second Prior License

2. Type

2. State

2. Year

15. If any of the following answers is Yes, explain at Section 20:

A. Have you ever used a name other than your current legal name or maiden name *

B. Have you been convicted of any criminal offense felony or misdemeanor *

C. Are charges pending against you on any criminal offense felony or misdemeanor *

D. Have you been convicted of any alcohol or drug related offense *

E. Have you or your spouse been fined, suspended, or denied a license by any racing commission or any board of stewards at a race track *

F. Have you ever been expelled, ejected, or denied privileges at any race track *

16. Most Recent Business or Employment in the Last 5 Years

16.1 Dates (from: to)

16.2 Dates (from: to)

16.1 Business Name/Address

16.2 Business Name/Address

16.1 Type of Business

16.2 Type of Business

16.1 Position Held

16.2 Position Held

17. Most Recent Address (other than current address) Where You Have Lived During the Last 3 Years

17.1 Dates (from:to)

17.1 Address

17.1 City

17.1 State

17.2 Dates (from:to)

17.2 Address

17.2 City

17.2 State

18. OWNERS

Your Trainer's Name

Horse List

Name(s) of Horses You Plan to Race in Nebraska This Year:

Horse 1 Name

Horse 2 Name

Horse 3 Name

Horse 4 Name

Horse 1 Age

Horse 2 Age

Horse 3 Age

Horse 4 Age

Horse 1 Other Owners

Horse 2 Other Owners

Horse 3 Other Owners

Horse 4 Other Owners

Horse 1 Your Share

Horse 2 Your Share

Horse 3 Your Share

Horse 4 Your Share

1. Foal Papers

2. Foal Papers

3. Foal Papers

4. Foal Papers

19. TRAINERS: List Owners for Whom You Are Now Training

19.1 Owner

19.2 Owner

19.3 Owner

19.4 Owner

19.1 Address

19.2 Address

19.3 Address

19.4 Address

19.1 Number of Horses

19.2 Number of Horses

19.3 Number of Horses

19.4 Number of Horses

20. Provide Explanation for Each YES Response to Section 15.

Include date(s), place(s), disposition(s)

Explanation A *

Explanation B *

Explanation C *

Explanation D *

Explanation E *

Explanation F *

I hereby certify that information provided on this application is true and correct to the best of my knowledge.

I hereby consent to review of any law enforcement records or reports concerning myself by representatives of the Nebraska Racing Commission.

I understand that failure to provide true and complete information, or failure to comply with Nebraska Rules of Racing may result in denial or revocation of this license. I understand as a licensee that I must disclose to the stewards and the commission any suspensions or revocations from any other jurisdiction while my Nebraska License is in effect. I must disclose this information no later than seventy-two (72) hours after the ruling has been issued.

I agree this application is executed and delivered by electronic means and upon such delivery the electronic signature will be deemed to have the same effect as if the original signature had been delivered to the other party.

Employer's Signature

Applicant's Signature *

Date *

Fingerprints

Nebraska statutes require submission of fingerprints and a criminal records check for most categories of applications. Applicants who have provided fingerprints in other racing jurisdictions that complete an FBI criminal history check when they issue a license may not be required to provide fingerprints in Nebraska.

For reciprocity consideration, an applicant must provide proof of fingerprinting during the current or the five prior calendar years.

1. This may be done by presenting or providing a copy of a license badge issued that shows the jurisdiction, date and year fingerprints were completed.

or

2. A letter or affidavit signed by a representative of another jurisdiction.

Issue Date of Fingerprints: *

Issue State of Fingerprints: *

Upload proof of fingerprint: *

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