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DBPRPMW-3030-E - DBPRPMW-3030-Effective-9-12-12--1.0--2012-07-30

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DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 1 of 9
1.1
DBPR PMW-3030 – Personal History Record
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DIVISION OF PARI-MUTUEL WAGERING
www.myfloridalicense.com
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
INSTRUCTIONS
This form is to be completed by all officers, directors, and persons holding an ownership interest in the
permit applicant, and should be completed in conjunction with Form DBPR PMW-3010 – Permit
Application.
PERSONAL INFORMATION
Social Security Number* Citizenship
Last Name First Middle Title Suffix
Maiden Name
Pseudonym (Alias, Nicknames, etc.)
Birth Date (MM/DD/YYYY)
/ /
Place of Birth
Gender
Male Female
Race/Ethnicity White Black Asian
Native American Other Hispanic
Eye Color Hair Color Height Weight
MAILING ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
CONTACT INFORMATION
Primary Phone Number Primary E-Mail Address
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City State Zip Code (+4 optional)
County (if Florida address) Country
*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In
this instance, disclosure of Social Security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654;
and Sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of
applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security
numbers must also be recorded on all occupational license applications and are used for licensee identification purposes pursuant
to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L. 193, Sec. 317.
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 2 of 9 1.1
BUSINESS ADDRESS
Employer Name
Position
Street Address
City State Zip Code (+4 optional)
County (if Florida address) Country
Business Telephone Business E-Mail Address
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number Fax Number
Alternate E-Mail Address
LIVING RELATIVES
MOTHER
Last Name First Middle Title Suffix
Maiden Name Birth Date (MM/DD/YYYY)
/ /
Place of Birth
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
FATHER
Last Name First Middle Title Suffix
Birth Date (MM/DD/YYYY)
/ /
Place of Birth
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 3 of 9
1.1
SIBLING
Last Name First Middle Title Suffix
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
SIBLING
Last Name First Middle Title Suffix
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
SIBLING
Last Name First Middle Title Suffix
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
SPOUSES/EX-SPOUSES
Last Name First Middle Title Suffix
Maiden Name Birth Date (MM/DD/YYYY)
/ /
Place of Birth
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 4 of 9 1.1
SON/DAUGHTER
Last Name First Middle Title Suffix
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
SON/DAUGHTER
Last Name First Middle Title Suffix
PRIMARY ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
RELATIVES IN PARI-MUTUEL WAGERING RELATED OCCUPATIONS
1. Last Name First Middle Title Suffix
Position Track/Fronton
Street Address or P.O. Box
City State Zip Code (+4 optional)
2. Last Name First Middle Title Suffix
Position Track/Fronton
Street Address or P.O. Box
City State Zip Code (+4 optional)
3. Last Name First Middle Title Suffix
Position Track/Fronton
Street Address or P.O. Box
City State Zip Code (+4 optional)
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 5 of 9 1.1
RELATIVES IN PARI-MUTUEL WAGERING RELATED OCCUPATIONS (CONT’D)
4. Last Name First Middle Title Suffix
Position Track/Fronton
Street Address or P.O. Box
City State Zip Code (+4 optional)
CRIMINAL HISTORY
Have you ever been convicted of any of the following? (check all that apply – if yes, explain below)
Bookmaking Felony
1. Date County State
Charge Disposition
2. Date County State
Charge Disposition
3. Date County State
Charge Disposition
PREVIOUS RESIDENCES (LAST 20 YEARS OR AGE 18, WHICHEVER IS LESS)
1. From To
Street Address
City State Zip Code (+4 optional)
County (if Florida address) Country
2. From To
Street Address
City State Zip Code (+4 optional)
County (if Florida address) Country
3. From To
Street Address
City State Zip Code
County (if Florida address) Country
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 6 of 9 1.1
EMPLOYMENT HISTORY
(SINCE AGE 21 – INCLUDING GOVERNMENT AND/OR MILITARY SERVICE)
1. From To
Employer/Military Branch
City State Position
2. From To
Employer/Military Branch
City State Position
3. From To
Employer/Military Branch
City State Position
4. From To
Employer/Military Branch
City State Position
5. From To
Employer/Military Branch
City State Position
6. From To
Employer/Military Branch
City State Position
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 7 of 9 1.1
INVESTMENTS IN GAMBLING ENTERPRISES
1. Business Organization Percentage Ownership
Street Address or P.O. Box
City State Zip Code (+4 optional)
2. Business Organization Percentage Ownership
Street Address or P.O. Box
City State Zip Code (+4 optional)
3. Business Organization Percentage Ownership
Street Address or P.O. Box
City State Zip Code (+4 optional)
4. Business Organization Percentage Ownership
Street Address or P.O. Box
City State Zip Code (+4 optional)
5. Business Organization Percentage Ownership
Street Address or P.O. Box
City State Zip Code (+4 optional)
6. Business Organization Percentage Ownership
Street Address or P.O. Box
City State Zip Code (+4 optional)
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 8 of 9 1.1
SOURCES OF INCOME OTHER THAN THOSE PREVIOUSLY LISTED
1.
2.
3.
4.
5.
6.
BANKING
1. Institution
Street Address or P.O. Box
City State Zip Code (+4 optional)
2. Institution
Street Address or P.O. Box
City State Zip Code (+4 optional)
3. Institution
Street Address or P.O. Box
City State Zip Code (+4 optional)
4. Institution
Street Address or P.O. Box
City State Zip Code (+4 optional)
DBPR PMW-3030, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 9 of 9 1.1
PERSONAL REFERENCES (OTHER THAN RELATIVES)
1. Full Name of Person Telephone Number
Street Address or P.O. Box
City State Zip Code (+4 optional)
2. Full Name of Person Telephone Number
Street Address or P.O. Box
City State Zip Code (+4 optional)
3. Full Name of Person Telephone Number
Street Address or P.O. Box
City State Zip Code (+4 optional)
ATTEST STATEMENT
Statement: I, the undersigned, understand that the foregoing information is being provided to the Division
of Pari-Mutuel Wagering pursuant to section 550.054, Florida Statutes. Furthermore, I certify that the
information provided herein is true, complete, and correct to the best of my knowledge subject to
penalties under section 837.06, Florida Statutes.
Subscriber Signature Date
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Completed 3 July 2020

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