1. Check one



* Employer's Signature Required


Other License:

Type Other License


First, Middle, Last


Hair Color
Eye Color

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



Marital Status


First Prior License
Second Prior License

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

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

Dates from/to
Dates from/to
Business Name/Address
Business Name/Address

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


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

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

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

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

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.

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.  


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

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