Fillable DBPRPMW-3190-E DBPR Letterhead Template

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DBPRPMW-3190-E DBPR Letterhead Template

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DBPR PMW-3190 – Officers and Directors
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DIVISION OF PARI-MUTUEL WAGERING
www.myfloridalicense.com
Please provide information on the partners, managers, officers, or directors for your business entity below.
ORGANIZATION NAME
Name of Organization Permit #
D/B/A or Trade Name
LIMITED LIABILITY CORPORATION QUESTIONS
If your corporation is a limited liability corporation (LLC), is the corporation member managed or manager
managed? You can check your Articles of Incorporation for this information.
Member Managed Manager Managed
Please list below all Officers, Directors, Managers, and/or Shareholders with 5 percent or more interest in the business:
Attach additional sheets as necessary.
MANAGEMENT INFORMATION
Last Name First Middle Title Suffix
Office Held
License #
Percentage of Ownership
RESIDENCE ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
MANAGEMENT INFORMATION
Last Name First Middle Title Suffix
Office Held
License #
Percentage of Ownership
RESIDENCE ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
DBPR PMW-3190, Effective 2016 December 13, Rule 61D-4.004, F.A.C. Page 1 of 2 Initial: __________ 2.0
MANAGEMENT INFORMATION
Last Name First Middle Title Suffix
Office Held
License #
Percentage of Ownership
RESIDENCE ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
MANAGEMENT INFORMATION
Last Name First Middle Title Suffix
Office Held
License #
Percentage of Ownership
RESIDENCE ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
MANAGEMENT INFORMATION
Last Name First Middle Title Suffix
Office Held
License #
Percentage of Ownership
RESIDENCE ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
OATH
I swear or affirm that the information provided in this application is true and complete. I understand that knowingly providing false
information on this application could subject the applicant to criminal penalties relating to perjury or other offenses.
_________________________ _________________________ ______________________________ _____________________
Name (Please Print) Title (Please Print) Signature Date
State of Florida,
County of __________________
Sworn to (or affirmed) and subscribed before me this ______ day of ______________________, 20____,
_________________________________________________, who is personally known to me or produced the following as identification:
____________________________________________________________________________________________________________.
______________________________
Notary Public
My Commission Expires: _________________________
DBPR PMW-3190, Effective 2016 December 13, Rule 61D-4.004, F.A.C. Page 2 of 2 2.0
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DBPRPMW-3190-E DBPR Letterhead Template

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Completed 3 July 2020

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