DBPR PMW-3180, Effective 9-11-11, Rule 61D-5.001, F.A.C. Page 1 of 1
1.1
DBPR PMW-3180 – Request for Waiver
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DIVISION OF PARI-MUTUEL WAGERING
www.myfloridalicense.com
TO: ___________________________ _______________ ___________________
Full Legal Name of Applicant Date of Birth Individual/Org. Number
If you are a new applicant to Florida and have been convicted of any felony, regardless of whether adjudication was
withheld, or if you are renewing your pari-mutuel occupat
ional license in Florida and have been convicted of any of
the crimes listed below, you must first request and receive a waiver from the Division Director in order to receive a
Florida Pari-Mutuel Wagering Occupational License or Cardroom License. Please check the appropriate box(es)
below that best describes your situation:
For Pari-Mutuel and Cardroom Applicants:
A conviction in this state, in any other state, or under the laws of the United States of a capital
felony, a felony or an offense in any other state which would be a felony under the laws of Florida
involving arson; trafficking in, conspiracy to traffic in, smuggling, importing, conspiracy to smuggle
or import, or delivery, sale, or distribution of a controlled substance; or a crime involving a lack of
good moral character. A felony or misdemeanor in this state, in any other state, or under the laws
of the United States, if such felony or misdemeanor is related to gambling or bookmaking, as
contemplated in Section 849.25, Florida Statutes, or involves cruelty to animals.
Currently under Suspension, Declared Ineligible, Ruled Off, Revoked, Denied, Ejected, Unpaid
Fine, in this or any other racing jurisdiction. Specify discipline and jurisdiction:
New applicant to Florida who has been convicted of any felony, regardless whether adjudication
was withheld.
For Cardroom Applicants Only:
A misdemeanor involving forgery, larceny, extortion, or conspiracy to defraud, in this state or any
other state, or under the laws of the United States.
If you choose to request a waiver, please sign this form below and return it with your completed application, license,
and fingerprint fees. After an investigation is conducted, the Division Director will either grant or deny the request for waiver.
You will be notified of the decision by mail at the address provided on your application.
UNTIL YOU ARE LICENSED:
1) You are not permitted to engage in any activity which requires a pari-mutuel occupational license or a cardroom license
at any pari-mutuel facility in Florida. If you are found to be working without a license, you will be subject to arrest for
trespassing and your waiver request may be denied.
2) You are forbidden from accessing any of the restricted areas of any pari-mutuel facility in Florida.
I hereby request a waiver for the situation(s) or conviction(s) noted above, and acknowledge that license and
fingerprint fees are non-refundable in the event the waiver request is denied. I hereby acknowledge that my failure to
participate in a waiver interview or to disclose any pertinent information regarding convictions, rulings, revocations, or
denials from other jurisdictions will result in a denial of the request for waiver. I hereby waive the Section 120.60,
Florida Statutes, timeline requirement regarding the processing of this application.
Signature of Applicant
Date
TO BE CONSIDERED FOR A WAIVER, APPLICANTS MUST COMPLETE FORM DBPR PMW-3195 – REQUEST FOR RELEASE OF
INFORMATION AND AUTHORIZATION TO RELEASE INFORMATION, AND SCHEDULE A WAIVER INTERVIEW WITH THE OFFICE OF
INVESTIGATIONS.
