Fillable DBPRPMW-3010-E - DBPRPMW-3010 Permit Application Effective-9-12-12--1.1--2012-07-30

Fill Online, Printable, Fillable, Blank DBPRPMW-3010-E - DBPRPMW-3010 Permit Application Effective-9-12-12--1.1--2012-07-30 Form

Use Fill to complete blank online MYFLORIDALICENSE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DBPRPMW-3010-E - DBPRPMW-3010 Permit Application Effective-9-12-12--1.1--2012-07-30

On average this form takes 20 minutes to complete

The DBPRPMW-3010-E - DBPRPMW-3010 Permit Application Effective-9-12-12--1.1--2012-07-30 form is 6 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 71 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your MyFloridaLicense forms online.

BROWSE MYFLORIDALICENSE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DBPR PMW-3010, Effective 9-12-12, Rule 61D-4.002, F.A.C Page 1 of 6
1.2
DBPR PMW-3010 – Permit Application
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL
REGULATION DIVISION OF PARI-MUTUEL WAGERING
www.myfloridalicense.com
INSTRUCTIONS
This form and its attachments are to be completed by individuals or businesses desiring to obtain a
Permit to Conduct Pari-Mutuel Wagering. Upon completion, the original notarized application and all
attachments should be returned to the Division.
At a minimum, the attachments include:
Request for Release of Information and Authorization to Release Information (Form DBPR PMW-3195)
Personal History Record (Form DBPR PMW-3030)
Individual Occupational License Application (Form DBPR PMW-3120)
SPECIAL NOTES
The following Florida Statutes and Rules are referenced for additional information required for
completing this application package.
Section 550.054, Section 550.0555, Section 550.0651, Section 550.0745, Section 550.1815, and
Section 550.334, Florida Statutes.
Rule 61D-4.002, Florida Administrative Code.
This application shall only be used when applying for a new pari-mutuel wagering permit. Please be
certain that all attachment numbers correspond with the numbers in the appropriate boxes throughout the
application.
SELECT PERMIT TYPE
Greyhound Racing
Thoroughbred Racing
Quarter Horse Racing
Harness Racing
Jai-Alai
Non-Wagering Meet
Name of Florida county in which racing will be conducted:
APPLICANT INFORMATION
Federal Employer ID Number/*Social Security Number
Applicant Name
Doing Business As (D/B/A) Name
Type of Ownership: Proprietorship All Corporations All Partnerships
Joint Venture Agreement Trust Estate
Other _________________________________________________________________________
MAILING ADDRESS
Street Address or P.O. Box
City State Zip Code (+4 optional)
County (if Florida address) Country
DBPR PMW-3010, Effective 9-12-12, Rule 61D-4.002, F.A.C Page 2 of 6
1.2
CONTACT INFORMATION
Contact Name
Primary Phone Number Primary E-Mail Address
BUSINESS LOCATION ADDRESS
Street Address
City State Zip Code (+4 optional)
County Country
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number Fax Number
Alternate E-Mail Address
1.
If the applicant is a Corporation, complete the following
:
(a)
Where incorp
orated:
W
hen incorporated:
(b)
Attach a copy of the Articles of Incorporation.
Attachment #
(c)
If incorporated outside of the State of Florida, attach a copy of license to do business in Florida.
Attachment #
(d)
Attach a copy of the last five corporate annual reports filed with the Department of State.
Attachment #
(e)
If the applicant corporation is a subsidiary of any other entity, attach an organizational chart
reflecting the complete holdings of the parent entity.
Attachment #
(f)
Attach a listing of all present or past civil suits involving the applicant as a defendant for the past
twenty years. Include style of case, case number, court of jurisdiction, and final outcome of case.
Attachment #
(g)
Attach a listing of all present or past criminal actions involving the applicant. Include investigating
agency, case number, and final outcome of case.
Attachment #
(h)
Attach a schedule disclosing all owners of 5 percent or more of any interest in this corporation.
Attachment #
DBPR PMW-3010, Effective 9-12-12, Rule 61D-4.002, F.A.C Page 3 of 6
1.2
(i) Attach a schedule disclosing defacto equity ownership where corporate debt exceeds 10 percent of
assets owed to any one party.
Attachment #
(j) Attach a sche
dule disclosing any ownership of 5 percent or more in any business or other entity
holding interest in any gambling or wagering activity in the State of Florida, the United States, or
internationally.
Attachment #
(k) Attach a sche
dule disclosing the structure of ownership and all individuals involved (refer to question
1(j) above).
Attachment #
(l) Attach a sche
dule disclosing the names and addresses of the officers and directors.
Attachment #
2. If the applica
nt is a Partnership, Joint Venture Agreement, Trust Agreement, or other business entity:
(a) Attach a copy of all agreements which established the entity.
Attachment #
(b) Attach a listin
g of all present or past civil suits involving the applicant as a defendant for the past
twenty years. Include style of case, case number, court of jurisdiction, and final outcome of case.
Attachment #
(c) Attach a listin
g of all present or past criminal actions involving the applicant. Include investigating
agency, case number, and final outcome of case.
Attachment #
(d) Attach a sche
dule disclosing the names and addresses of the principals, partners, or shareholders
owning 5 percent or more of the business entity.
Attachment #
(e) If the applica
nt is a subsidiary of any other entity, attach an organization chart reflecting the
complete holdings of the parent entity.
Attachment #
(f) Attach a sche
dule disclosing any ownership of 5 percent or more in any business or other entity
holding interest in any gambling or wagering activity in the State of Florida, the United States, or
internationally.
Attachment #
(g) Attach a sche
dule disclosing the structure of ownership and all individuals involved (refer to question
2 (f) above).
Attachment #
DBPR PMW-3010, Effective 9-12-12, Rule 61D-4.002, F.A.C Page 4 of 6
1.2
3. The following financial information is required for applicants which are Corporations, Partnerships, Joint
Venture Agreements, Trust Agreements, or other business entities:
(a) Attach a copy of the applicant's financial statements for the last five years. If no financial statements
were prepared, so state, and attach necessary documents which reflect the financial condition of the
applicant for the past five years.
Attachment #
(b)
If the applicant is a subsidiary of any other entity, the applicant must attach a copy of the parent
corporation's financial statements for the past five years. If no financial statements were prepared
for the parent corporation, so state, and attach necessary documents which reflect the financial
condition of the parent corporation for the past five years.
Attachment #
(c)
Please attach the names and addresses of the ultimate equitable owners for a corporation or other
business entity, if different from those provided in 1(h), 1(l), and 4(a), unless the securities of the
corporation or entity are registered pursuant to s. 12 of the Securities Exchange Act of 1934, 15
U.S.C. ss. 78a-78kk; and if such corporation or entity files with the United States Securities and
Exchange Commission the reports required by s. 13 of that act or if the securities of the corporation
or entity are regularly traded on an established securities market in the United States.
Attachment #
4. Own
ership Interest
s
(a)
Provide the full name, legal residence, business address, and percentage of ownership and
total
numbe
r of shares held, of all parties holding an interest in the applicant.
Attachment #
(b)
All ownership interests must complete a Personal History Record, as included in the permit
application package; a Request for Release of Information and Authorization to Release Information,
as included in the permit application package; and a Division of Pari-Mutuel Wagering fingerprint
card, as included in the permit application package.
Attachment #
(c)
Attach a listing of all past or present criminal charges involving the above-listed ownership interests
and their spouses; if none, so state. Include arrest charge, arresting agency, date of arrest, court of
jurisdiction, and final outcome.
Attachment #
(d)
Attach a listing of all past or present civil suits involving the above-listed ownership interests and
their spouses; if none, so state. Include style of case, case number, court of jurisdiction, and final
outcome of case.
Attachment #
(e)
All ownership interests shall make available for division inspection a copy of all income tax returns
filed for the past five years, including spouses. Said inspection shall be conducted at a time and
place designated by the division.
(f) All ownership interests shall provide an audited financial statement, with an independent CPA
opinion, of their personal financial condition as of the date of the application.
Attachment #
(g)
All ownership interests shall attach a listing of all occupational and/or professional licenses held by
them, their spouses, or any associated business entity under the jurisdiction of any federal, state,
county, or municipal authority and a statement indicating whether administrative proceedings were
DBPR PMW-3010, Effective 9-12-12, Rule 61D-4.002, F.A.C Page 5 of 6
1.2
ever initiated against any of the listed licenses. Include type of proceeding, agency initiating the
proceedings, date, and final outcome of case.
Attachment #
(h)
All ownership interests shall attach a statement indicating if they, their spouses, or any associated
business entities have ever filed for bankruptcy.
Attachment #
(i)
All ownership interests shall attach a listing of the full name, legal address, business address, and
date of birth of any divorced spouse or divorce proceedings involving the current spouse.
Attachment #
5.
All applicants shall provide:
(a) A detailed statement (with supporting evidence) of the method of financi
ng the
purcha
se/construction of the facility, and first year's operating expenses. Said statement shall
include a complete disclosure of the sources of funds.
Attachment #
(b)
A statement detailing all preliminary plans with respect to the operation of the facility, including the
names of management personnel and racing officials, and any arrangements to obtain contractual
services such as totalisator equipment, video equipment, food service, security service,
housekeeping, and maintenance service.
Attachment #
(c)
A complete listing of any loans obtained by the applicant within the past two years, including the
name of lender, amount of loan, terms of loan, collateral, reason for loan, and a copy of loan
agreements.
Attachment #
(d)
A legal description of the property where the proposed pari-mutuel facility is or will be located.
Attachment #
(e)
Applicant's control over the above-described property is by:
[ ] Ownership
[ ] Lease
[ ] Other Authority
Copies of all deeds, titles, contracts or agreements concerning the acquisition of land where the
facility is or will be located. Said documents shall reflect applicant's control of property, method of
financing the acquisition of the property, and sources of funds.
Attachment #
(f)
An aerial view or detailed area map depicting the location of the facility, adjacent barn or kennel
areas, and access roads.
Attachment #
(g)
Preliminary plans and drawings detailing the construction of the proposed pari-mutuel facility,
including backside areas. The dimensions of the facility, type of construction, seating capacity, barn
size and design, and facilities for handling the public.
Attachment #
DBPR PMW-3010, Effective 9-12-12, Rule 61D-4.002, F.A.C Page 6 of 6
1.2
(h) A listing of all contractors used in the construction of the facility. A copy of contracts between the
applicant and the contractors shall be provided to the division no less than ten working days after
finalization of the contracts.
Attachment #
(i)
If a facility previously existed, a copy of all contracts or agreements concerning the acquisition of
existing assets (sales agreement).
Attachment #
(j)
If the permit is to be used for quarter horse racing, a statement that the permit will be used for
quarter horse racing within one year of the date on which the permit is granted, or, if the facility is not
already built, a statement that substantial construction will be started within one year of the issuance
of the permit.
Attachment #
NOTARIZATION
The fore
going application was sworn to and subscribed before me this
day of 20
b
y
,
Type or print name of applicant’s representative Signature of applicant’s representative
who i
s personally known to me or who has produced the following as identification:
Type of identification
Signature of person taking acknowledgement
(Stamp
and Expiration)
*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this
instance, disclosure of Social Securit
y numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and
Sections 409.2577, 409.2598, and 559.79, Florida Statute. 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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DBPRPMW-3010-E - DBPRPMW-3010 Permit Application Effective-9-12-12--1.1--2012-07-30

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document