DBPR PMW-3120, Effective 9-11-11, Rule 61D-5.001, F.A.C. Page 2 of 2 1.2
BACKGROUND INFORMATION
Yes No Have you ever been convicted of or had adjudication withheld for any crime, or pled guilty or nolo
contendere to any criminal charges against you? If yes, the court disposition records for all convictions
listed must be submitted with this application and list the details in the section provided below.
DATE OF
DISPOSITION
COUNTY STATE OFFENSE MISDEMEANOR
OR FELONY?
SENTENCE
Yes No N/A Have you ever had a racing/gaming license suspended, revoked, or denied in this or any other
state or country? If yes, give details in the space provided below.
INCIDENT DATE RACING
JURISDICTION
OFFENSE DISCIPLINE (suspension, fine, declared
ineligible, denied, etc.) Indicate whether the
discipline has been satisfied.
TO BE COMPLETED BY CARDROOM APPLICANTS ONLY
Yes No Have you ever been convicted of, or had adjudication of guilt withheld for, a misdemeanor
involving forgery, larceny, extortion, conspiracy to defraud, or filing false reports to a government
agency, racing or gaming commission or authority, in this state or any other state under the laws
of the United States?
ALL APPLICANTS PLEASE READ AND SIGN BELOW
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, 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.
Each application for a license or renewal of a license issued by the Department of Business and Professional Regulation shall
be signed under oath or affirmation by the applicant, or owner or chief executive of the applicant without the need for witnesses
unless otherwise required by law.
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I understand that my
signature on this application has the same legal effect as if made under oath. To the best of my knowledge, all information
contained on this application is true and correct. I understand that falsification of any information on this application may result
in administrative action, including fines up to $1,000, denial, suspension or revocation of the license. I agree to abide by and
obey all rules and regulations of the Division of Pari-Mutuel Wagering and the laws of the State of Florida, pursuant to Section
550.105, Florida Statutes.
__________________________________________________ ________________________
Signature of Applicant Date
