ELECTRONIC WAGERING TERMINAL PILOT PROGRAM …agreement with a person or entity to conduct, manage...

Version January 10, 2013

ELECTRONIC WAGERING TERMINALPILOT PROGRAM LICENSE

APPLICATION

NEW JERSEY RACINGCOMMISSIONP.O. BOX 088

TRENTON, NJ 08625-0088609-292-0613

The New Jersey Racing Commission (hereinafter “Commission”), pursuant toN.J.S.A. 5:5-186 et seq., known as the “Off-Track and Account Wagering PilotProgram Act” (hereinafter “Act”), has been authorized to implement a pilotprogram to license a lessee or purchaser of a State-owned racetrack to providepatrons with the ability to place wagers on horse races through electronicwagering terminals to be located at a limited number of eligible taverns,restaurants, and similar venues where food, alcoholic beverages, or both, areserved to the public for on-premises consumption in Bergen, Hudson, Essex,Passaic, Union, Morris, Somerset, Hunterdon, Warren, Sussex, northernMiddlesex and northern Ocean counties (that is, venues selected by the pilotprogram applicant). Pursuant to this authorization, the Commission has the fullpower to prescribe rules, regulations and conditions under which an ElectronicWagering Terminal Pilot Program wagering license is issued in this State, and torevoke, suspend or refuse to renew a license if in the opinion of the Commissionthe revocation of, suspension of or refusal to renew such license is in the publicinterest.

Pursuant to the powers vested in it by the Act, the Commission has promulgatedregulations governing the conduct of Electronic Wagering Terminal Pilot Programwagering in this State, which appear at N.J.A.C. 13:74B et. seq. In accordancewith the Act and N.J.A.C. 13:74B, the Commission has prescribed the within“Electronic Wagering Terminal Pilot Program License Application” to be completedjointly by a lessee or purchaser of a State-owned racetrack and that entity’sselected taverns, restaurants or similar venue(s) located within the above-referenced geographic regions. Upon the filing of this completed application, theCommission shall consider such application pursuant to the procedure set forthin its rules

Any “Electronic Wagering Terminal Pilot Program” license issued to the applicantshall specify the effective dates of the license, the location of the selected venue(s)subject of the license, the periods of time during the calendar year and themaximum hours of operation during which wagering is permitted at the selectedvenue(s), and such other terms or conditions which may be imposed by theCommission in accordance with the Act and N.J.A.C. 13:74B, as appropriate.

_________________________________________________________________________________

N.J.R.C. USE ONLY

LIC. NO. ____ _____ ___________ YR LOC NUMBER

RCPT. NO. ____ _____ ___________ YR LOC NUMBER

ID NO.: _________________________

N.J.R.C. USE ONLY

RCPT. DATE _______ OPER ______

CHECK _________ $_____________

MO _________ $_____________

of 28Version January 10, 2013

In making this application, the applicant, and venue(s) selected by the applicant,acknowledge that each is required to provide full and complete answers anddisclosures to all questions asked, and that any related license granted by theCommission is predicated upon the accuracy and completeness of the informationprovided in this application.

If the space allotted within this application is not sufficient to provide an accurateand complete answer, or where the submission of an attachment is specificallyrequired, the applicant (and/or venue selected by the applicant) shall attach suchadditional pages as are necessary to complete the response thereupon. Where theapplicant (and/or venue selected by the applicant) furnishes an attachment to thisapplication in response to any question, the applicant (and/or venue selected bythe applicant) shall insert the phrase “see attached” in the answer space on thisapplication form. In all cases, the applicant (and/or venue selected by theapplicant) shall label the attachment page with the corresponding questionnumber within this application.

Part A - To Be Completed By Lessee Or Purchaser of State-ownedRacetrack

Pursuant to the Act, the undersigned (“pilot program applicant”) hereby makesapplication for an Electronic Wagering Terminal Pilot Program license, asdesignated immediately below, to the Commission:

(__) Initial Application, which application is accompanied by a non-refundable filing fee of $2,500. [see N.J.A.C. 13:74B-2.1(b)].

A1a) Please provide the full and proper name of the pilot program applicant.

________________________________________________________________________________________________________________________________________________

A1b) Provide the principal address of the pilot program applicant.

A1c) Provide the principal telephone number of the pilot program applicant.

________________________________________________________________________


A1d) Provide the name, address and telephone number of the natural person whois authorized to accept service of process on behalf of the pilot programapplicant.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

A2a) Provide the full and proper name (as well as any “doing business as”,“d/b/a” name) of each proposed Electronic Wagering Terminal PilotProgram venue (“selected venue”). Attach an addendum, if necessary.Please also provide (through an attachment) a copy of the written contractor agreement between the pilot program applicant and each selected venue.If no such contract or agreement exists as concerns any selected venue,provide a written explanation as to why no such document is available.

AA2b) Provide the principal address of each selected venue. Attach an addendum,if necessary.

A2c) Provide the principal telephone number of each selected venue. Attach anaddendum, if necessary.________________________________________________________________________________________________________________________________________________________________________________________________________________________


________________________________________________________________________A3) Has the pilot program applicant entered into an agreement with the New

Jersey Sports & Exposition Authority (“ NJSEA “) for the sale or lease of aState-owned racetrack to it? If yes, please attach a copy of such agreementto this application.

Yes ______ No _____

A4) Has the pilot program applicant been issued a permit by the Commissionto conduct a horse race meeting at said racetrack [See N.J.A.C. 13:74B-1.2(b)1]?

Yes ______ No _____

A5) Attach to this application a copy of a fully executed off-track wageringparticipation agreement, which the applicant has become a party to [SeeN.J.A.C. 13:74B-1.2(b)2]. Is such participation agreement attached?

Yes ______ No ______

If yes, please answer the following additional question:

List the parties to the participation agreement (with the exception of theapplicant), the principal address of each, and the principal telephonenumber of each.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

A6) Provide the name, address and telephone number of the natural personwho is authorized to accept service of process on behalf of each party to theparticipation agreement.


________________________________________________________________________

A7) Without incorporating the participation agreement by reference in yourresponse, attach an addendum to this application explaining in detail thepilot program applicant’s participatory role in the pilot program wageringsystem and any participatory role of persons and/or entities other than theapplicant in the pilot program wagering system, including but not limitedto the parties to the participation agreement. Is such an addendumattached?

Yes ______ No ______

A8) Has the applicant entered into, or does it intend to enter into, a contract oragreement with a person or entity to conduct, manage or operate the pilotprogram wagering system for it, and/or for such person or entity to act asits agent in pilot program wagering matters subject to and approved by theCommission?

Yes ______ No ______

If yes, through an attachment, explain and attach such contract oragreement, if presently entered into. If yes, please provide a detailednarrative explaining the contract or agreement, and relationship betweenthe applicant and management entity relating to the conduct of the pilotprogram wagering system, including the financing thereof.

Is such attachment included?

Yes ______ No ______

A9) Has the pilot program applicant entered into any contract or agreementwith another licensed entity, that has also entered into an agreement withthe NJSEA for the sale or lease of a State-owned racetrack which has alsoreceived a race permit from the Commission, under which the parties wouldshare the proceeds from the licensed activities of the pilot program wageringsystem [See N.J.A.C. 13:74B-1.2(d)]?

Yes ______ No ______

If yes, attach a copy of the executed agreement and indicate through an


attachment (with supporting documentation) whether or not the agreementhas been approved by the NJSEA. Is such attached?

Yes ______ No ______

A10a) Identify the proposed location (complete address) of the hub facilitywithin this State, which facility shall service the pilot programwagering system.

A10b) Is this the same hub facility being utilized in connection with theaccount wagering system and off-track wagering system ?

Yes ______ No ______

If No, is the applicant as part of this application seeking RacingCommission approval to utilize a hub facility different from thatbeing utilized in connection with the account wagering system andoff-track wagering system?

Yes ______ No ______

A11) Identify the following information concerning the proposed vendor of thehub facility, which facility is to be utilized in connection with the pilotprogram wagering system ?

Vendor Name: _________________________________________________

Principal Address: ________________________________________________

________________________________________________

Principal Telephone Number: __________________________________________

A12) Has the applicant entered into a written contract or agreement with thevendor, as described in the response to question A11 to this application, inconnection with the hub facility to be utilized in connection with the pilot


program wagering system subject of this application?

Yes ______ No ______

If yes, attach a copy of the written contract or agreement. Is suchcopy attached?

Yes ______ No ______

A13) Please attach an addendum providing complete and specific informationregarding the electronic wagering terminals the pilot program applicantintends to use in the pilot program wagering selected venue(s), and provideevidence that such terminals comply with the requirements set forth inN.J.A.C. 13:70, 13:71, 13:74, and 13:74B-2.1(d)5. This information shouldinclude, but not be limited to, the manufacturer/model of the selectedterminals, history of use of such machines in this and other jurisdictions,as well as the number of terminals proposed for each selected venue. Issuch attached?

Yes _____ No ______

A14) Provide the following information concerning the primary bank utilized bythe pilot program applicant (name, address, telephone number) inconnection with its pilot program wagering system.

A15) Has the pilot program applicant, or any person or entity acting on behalfof the applicant, entered into any financing arrangement with any bank,financial institution, individual or third party to provide funding to be useddirectly or indirectly in connection with the pilot program wagering system?

Yes ______ No ______


If yes, identify the parties subject of the financing arrangement andthe details concerning the financing and securement thereof?

Will any racing-related revenues, or other non-financed monies, be utilizedto finance the start-up and operation of the pilot program wagering system?

Yes ______ No ______

If yes, include an attachment which discloses, in detail, the particularsource of those racing-related revenues, or other non-financedmonies.

Attach as an verified documentation (such as financial statements) whichdetails and establishes that the pilot program applicant has sufficientfinancial resources to effectively and successfully implement and operatethe pilot program wagering system subject of this application. Is suchattached?

Yes ______ No ______

A16) Please attach a “Table of Organization” setting forth with specificity:

a) the identity of the pilot program applicant and its constituency (e.g.,in the case of a corporation, the Board of Directors, Officers, etc.);

b) the identity and constituency of each entity (including but not limitedto the pilot program applicant), affiliate or agent of the pilot programapplicant which will have any management, administrative and/oroversight responsibility with respect to any aspect of the pilotprogram wagering system or related licensure duties; and the identityof each employee or person who will have any managerial,administrative or oversight responsibility on behalf of each identifiedentity, affiliate or agent.

Is such a “Table of Organization” attached?

Yes_______ No_______


c) For the pilot program applicant and each entity, affiliate or agentidentified in the “Table of Organization” attached to this applicationin response to questions A16 a) and b), attach a “Table (or Tables) OfOwnership” identifying any parent corporation(s), parent entities(partnerships, etc.), or person(s) which holds any ownership interestin said pilot program applicant, entity or agent. This question shouldbe answered in a fashion so that the Commission is fully apprised ofall direct and indirect owners (except that, where a publicly tradedcorporation, holders of less than a 5% interest need not be disclosed)of the pilot program applicant, as well as with respect to any entity,affiliate or agent of the pilot program applicant which will have anymanagement, administrative or oversight responsibility with regardto the subject of this application.

Is such a table (or tables) attached?

Yes ______, a table for each entity, affiliate or agent is attached.Yes ______, a table for one or more (but not all) entities, affiliates or agentsis attached.No ______, no tables are attached.

If the answer to question 16 c) is “yes, a table for one or more (but notall) entities, affiliates or agents is attached,” or “no, no tables areattached,” list each entity below for which such table is not attachedand provide an explanation why that respective table is not attached:

A17) To the pilot program applicant’s knowledge, has any entity or persondisclosed in completing this application (Part A) ever been convicted of anycrime?

Yes ______ No ______

If yes, provide the particulars?


A18) To the pilot program applicant’s knowledge, has any entity or persondisclosed in completing this application (Part A) ever been suspended,denied a license or ruled off by this or any other Racing Commission or turfgoverning body?

Yes ______ No ______

If yes, give particulars?

A19) To the pilot program applicant’s knowledge, is any entity or persondisclosed in completing this application (Part A) presently the subject of anypending criminal investigation, criminal complaint, criminal charges orcriminal indictment?

Yes ______ No ______


A20) To the pilot program applicant’s knowledge, is any entity or persondisclosed in completing this application (Part A) presently subject of anycivil proceeding where the potential liability may exceed $10,000?

Yes ______ No ______


A21) To the pilot program applicant’s knowledge, is any entity or person


disclosed in completing this application (Part A) the subject of any pendinginvestigation or pending complaint by any federal or state agency orregulatory body?

Yes ______ No ______


A22) Identify below the name and employment position of the individual who hadthe primary responsibility on behalf of the pilot program applicant tocomplete this application (Part A)?

A23) Identify below the name and employment position of the high managerialagent (required) who, on behalf of the pilot program applicant, and in thesignature space below, is attesting that the disclosures within thisapplication (Part A) are to the best of his or her knowledge true, accurateand complete, as required by N.J.A.C. 13:74-2.1(d)8.


CERTIFICATION OF PILOT PROGRAM APPLICANT (PART A TOAPPLICATION)

I, ___________________________, being duly authorized to execute thisapplication on behalf of the pilot program applicant, certify that the answers anddisclosures within this application and its attachments to the best of myknowledge are true, accurate and complete.

Sworn and subscribed tobefore me this _______day of _____________, 20___.

________________________________________A Notary Public of New Jersey

My Commission expires ___________________


Part B - To Be Completed Jointly By Pilot Program Applicant AndElectronic Wagering Terminal Pilot Program Venue Selected By The Pilot

Program Applicant (“Selected Venue”)

In making this application, the applicant, and venue selected by the applicant,acknowledge that each is required to provide full and complete answers anddisclosures to all questions asked, and that any related license granted by the NewJersey Racing Commission (“Commission”) is predicated upon the accuracy andcompleteness of the information provided in this application.

If the space allotted within this application is not sufficient to provide an accurateand complete answer, or where the submission of an attachment is specificallyrequired, the applicant (and/or venue selected by the applicant) shall attach suchadditional pages as are necessary to complete the response thereupon. Where theapplicant (and/or venue selected by the applicant) furnishes an attachment tothis application in response to any question, the applicant (and/or venue selectedby the applicant) shall insert the phrase “see attached” in the answer space onthis application form. In all cases, the applicant (and/or venue selected by theapplicant) shall label the attachment page with the corresponding questionnumber within this application.

This application (Part B) incorporates by reference the four paragraphs which arefound at pages 1 and 2 to this application, and which precede Part A to thisapplication. A separate “Part B’ to this application is required for each selectedvenue.

_________________________________

B1a) Please identify the location, business name (include any “doing businessas”, “d/b/a” name), and full address of the selected venue .

B1b) In an attachment, identify the names and addresses of the presentownership and management of the selected venue. Also identify whether ornot any owner or manager of the facility resigned or was otherwiseterminated in the twelve (12) month period preceding the date of the filingof this application, and if so, identify the name and address of suchperson(s). Is an attachment, providing this information, included?

Yes ____ No ____


B1c) Under what form of business does the selected venue operate or intend tooperate (e.g. corporate, partnership, etc.)?

_________________________________________

Attach a copy of the paperwork related to the form of business under whichthe selected venue operates. Is such attached?

Yes ____ No _____ (if no, explain why not in anattachment)

B1d) Please provide the name, address and telephone number of the naturalperson who is authorized to accept service of process on behalf of theselected venue. Attach an addendum, if necessary.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B1e) Identify whether or not the selected venue is a presently operating business,and the County within which the selected venue is/will be located. Alsoindicate whether the selected venue is presently operating a restaurant ortavern, or other than a restaurant or tavern, and whether it serves food,whether it serves alcohol, and the type(s) of non-gaming amenities presentlyavailable at the premises.

B1f) Identify the municipality (legal name) in which the selected venue is/will belocated.


B1g) Identify the distance in miles (both by vehicle/shortest route, and “as thecrow flies”), as well as time of travel by ground transportation, between theselected venue and each racetrack, off-track wagering facility andsimulcasting facility that is planned or existing in the State of New Jersey.Attach an addendum, if necessary.

B1h) Explain, in an attachment, with particularity, why the selected venue,under the applicable law and rules of the Commission, is an eligible tavern,restaurant or similar venue. Is such an addendum attached?

Yes _____ No ______

B1i) Explain in an attachment, with specificity, why the applicant and selectedvenue, under the rules of the Commission, particularly at N.J.A.C. 13:74B-2.1(f)4, believe each has the ability comply with said rules? Is such anaddendum attached?

Yes _____ No ______

B1j) Explain in an attachment, with particularity, why the pilot programapplicant and selected venue, under the rules of the Commission, believethe issuance of a license for the establishment of electronic wageringterminals at the selected venue would not be inimical to the interests of aplanned or existing racetrack, off-track wagering facility, or simulcastingfacility?

In answering this question, please specifically (under a labeledcorresponding heading) address each of the following geographic proximityand impact criteria: the distance in miles between the selected venue andany racetrack, off-track wagering facility, or simulcast facility; the time ittakes to travel between the selected venue and any racetrack, off-trackwagering facility, or simulcast facility; any proposed plans intended toattract a new wagering population within the area of proximity to anyracetrack, off-track wagering facility, or simulcasting facility; availablewagering data or market analyses evaluating the wagering population, its


saturation, and the wagering draw areas in proximity to any racetrack, off-track wagering facility, or simulcasting facility and in proximity to theproposed selected venues (include any such evaluations commissioned orconducted). Is such an addendum attached?

Yes _____ No ______

B1k) Does the pilot program applicant or selected venue have any writing, orother evidence, addressing whether any racetrack, off-track wageringfacility, or simulcasting facility in proximity to the selected venue opposes,consents, or takes no position regarding the licensure of the selected venue?

Yes _____ (if yes, attach any supporting explanation anddocumentation)

No _____

B2) Has the governing body of the local municipality within which the selectedvenue is to be situated issued any and all approvals necessary to be issuedby it?

Yes ______ No ______

If No, state whether any such approvals are necessary and explain therequirements in detail:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are any additional governmental approvals, aside from the approval of theCommission or the local municipality (if any), necessary for the selectedvenue to conduct operations in relation to the pilot program wageringsystem?

Yes ______ No ______

If Yes, explain the nature of those required governmental approvals withregard to the selected venue, and whether or not each has beenaccomplished?

______________________________________________________________________________________________________________________________________________________________________________________________________


____________________________________________________________________________________________________________________________________

B3a) Does the pilot program applicant, and selected venue, each understandthat, in addition to the pilot program applicant (including its agents andemployees, as determined by the Commission consistent with its rules)needing to be issued a license, that the selected venue (including its agentsand employees, consistent with the rules of the Commission) will need to belicensed by the Commission?

Yes ______ No _______

B3b) Please attach a letter, of the New Jersey Sports & Exposition Authorityindicating its position (in favor/opposed/no position/neutral, etc.) withregard to the Commission’s determination on this application as to the pilotprogram applicant, and as to the selected venue. Is such attachmentincluded?

Yes ______ No ______

B4a) Attach an addendum to this application (which could include diagrams),pursuant to the requirements of N.J.A.C. 13:74B-2.1(f) and thisapplication, detailing:

- the location, physical plan and security of the selected venue, and adescription including:

- the space relationship between wagering and non-wagering relatedamenities;

- the number of employees at the selected venue- the number of jobs expected to be created at the selected venue;- the gross revenues expected to be generated by the selected venue;- the fire evacuation plan for the selected venue;- the type of food and beverages to be available;- if alcoholic beverages are to be served at the facility, whether the

requirements of law have been satisfied;- the proposed hours of operation (including days of week, hours of

day) of the selected venue and- the proposed number of electronic wagering terminals at the selected

venue.

Is such an addendum attached?

Yes ______ No ______


B4b) Does the selected venue’s physical plan include provisions for theinstallation of security and surveillance equipment in public and non-publicareas of the facility (to include closed circuit television) to enhance safetyand the integrity of wagering?

Yes ______ No ______

If yes, is the physical plan consistent with allowing the Commission accessto the system or its signal to the same extent as the employees of theselected venue?

Yes ______ No ______

B4c) Does the selected venues facility physical plan include the establishment ofa “money room” within the premises of the facility?

Yes ______ (if yes, provide details in an attachment)

No ______ (if no, explain in detail how the proceeds ofwagering are intended to be stored, secured, andproperly accounted for)

B5) Attach as an addendum to this application a copy of the internal controlprocedures regarding the pilot program wagering system, and the selectedvenue, as required by N.J.A.C. 13:74B-2.1(f)7 and 13;74B-2.4(d). Is suchan addendum attached?

Yes ______ No ______

If yes, indicate whether the internal control procedures include thefollowing:

Procedures to be implemented to effectively operate and manage thewagering activities at the selected venue.

Yes ______ No ______

Procedures to be implemented to effectively maintain the integrity ofwagering and the proceeds from wagering associated with the selectedvenue.

Yes ______ No ______


Procedures designed to accurately account for and track proceeds fromwagering from the time the related wager is placed through delivery to themoney room/secured location and ultimate distribution therefrom.

Yes ______ No ______

Procedures to foster and insure that the selected venue, if licensed by theCommission to participate in the pilot program wagering system, complieswith the requirements of the P.L. 2011, c. 228 and N.J.A.C. 13:74B.

Yes ______ No ______

Explain below whether the internal control procedures, provided inresponse to this question to the application, apply to the pilot programapplicant, the selected venue, both the pilot program applicant and selectedvenue, or other?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B5a) Attach as an addendum to this application a copy of any separate internalcontrol procedures of the selected venue, which are directed to theoperations of its own business and proposed business activities as aparticipant in the pilot program wagering system. Are such internal controlprocedures attached?

Yes ______ No ______

If No, explain why not in an attachment.

B6) Attach an verified supporting documentation (such as financial statements)which details and establishes the selected venue’s availability of financialresources to sufficiently enable it to establish and conduct pari-mutuelwagering through the electronic wagering terminals, with appropriatelystaffed and managed operations. Is such attachment included?

Yes ______ No ______


B7) Identify below the full name(s) and address(es) of any current or intended(if known) employees of the selected venue, whose job responsibilities areexpected to include involvement with the wagering activity which is thesubject of this application. Attach an addendum, if necessary.

B8) Does the pilot program applicant and/or selected venue intend to devisean identification tag to be worn by its employees at the premises of theselected venue?

Yes ______ (if yes, explain particulars in an attachment,including whether the applicant or selected venueshall have such responsibility)

No ______

B9a) Please acknowledge whether the applicant and selected venue have read,and are each familiar with, the Act and rules of the Racing Commissionrelated to this application, including at N.J.A.C. 13:74B et. seq.?

Yes ______ No ______

B9b) N.J.A.C. 13:74B includes requirements for this application to beconsidered complete, as well as criteria to be considered in the RacingCommission’s consideration of the application. Through this question, theapplicant and selected venue is being provided opportunity to supplementthis application with any information, comments or materials which theapplicant, in view of these rules, believes is required or relevant to thewithin application. Is any supplemental information or materials attached?

Yes _____ No ______

B10a) Is the selected venue presently licensed by any state agency?

Yes ____ (if yes, attach true copy of any licenses)

No ____


B10b) Has the selected venue ever been the subject of any enforcementaction by any state or federal agency?

Yes ____ (If yes, explain details in attachment)

No ____

B10c) Has the selected venue ever been the subject of a penalty imposed byany state or federal agency?


No ____

B10d) Has the selected venue ever conducted business operations under adifferent name?


No ____

B11) To the pilot program applicant’s knowledge, has any entity or persondisclosed in completing this application (Part B) ever been convicted of anycrime?

Yes ______ No ______


B12) To the pilot program applicant’s knowledge, has any entity or persondisclosed in completing this application (Part B) ever been suspended,denied a license or ruled off by this or any other Racing Commission or turfgoverning body?

Yes ______ No ______



B13) To the applicant’s knowledge, is any entity or person disclosed incompleting this application (Part B) presently the subject of any pendingcriminal investigation, criminal complaint, criminal charges or criminalindictment?

Yes ______ No ______


B14) To the pilot program applicant’s knowledge, is any entity or persondisclosed in completing this application (Part B) presently subject of anycivil proceeding where the potential liability may exceed $10,000?

Yes ______ No ______


B15) To the pilot program applicant’s knowledge, is any entity or persondisclosed in completing this application (Part B) the subject of any pendinginvestigation or pending complaint by any federal or state agency orregulatory body?

Yes ______ No ______



B16) Identify below the name and employment position of the individual who hadthe primary responsibility, on behalf of the pilot program applicant, tocomplete this application (Part B)?

B17) Identify below the name and employment position of the high managerialagent (required) who, on behalf of the pilot program applicant, and in thesignature space below, is attesting that the disclosures within thisapplication (Part B) are to the best of his or her knowledge true, accurateand complete, as required by N.J.A.C. 13:74B-2.1(f)8.

B18) To the selected venue’s knowledge, has any entity or person disclosed incompleting this application (Part B) ever been convicted of any crime?

Yes ______ No ______



B19) To the selected venue’s knowledge, has any entity or person disclosed incompleting this application (Part B) ever been suspended, denied a licenseor ruled off by this or any other Racing Commission or turf governing body?

Yes ______ No ______


B20) To the selected venue’s knowledge, is any entity or person disclosed incompleting this application (Part B) presently the subject of any pendingcriminal investigation, criminal complaint, criminal charges or criminalindictment?

Yes ______ No ______


B21) To the selected venue’s knowledge, is any entity or person disclosed incompleting this application (Part B) presently subject of any civil proceedingwhere the potential liability may exceed $10,000?

Yes ______ No ______



B22) To the selected venues knowledge, is any entity of person disclosed incompleting this application (Part B) the subject of any pending investigationor pending complaint by any federal or state agency or regulatory body?

Yes ______ No ______


B23) Identify below the name and employment position of the individual who hadthe primary responsibility on behalf of the selected venue (Part B) tocomplete this application?

B24) Identify below the name and employment position of the high managerialagent (required) who, on behalf of the selected venue, and in the signaturespace below, is attesting that the disclosures within this application (PartB) are to the best of his or her knowledge true, accurate and complete, asrequired by N.J.A.C. 13:74B-2.1(f)8.


CERTIFICATION OF PILOT PROGRAM APPLICANT (PART B TOAPPLICATION)

I, _______________________, being duly authorized to execute this application onbehalf of the pilot program applicant, certify that the answers and disclosureswithin this application (Part B) and its attachments to the best of my knowledgeare true, accurate and complete.

Sworn and subscribed to_______________________________________before me this _______day of __________________.

_________________________________________A Notary Public of New Jersey



CERTIFICATION OF SELECTED VENUE (PART B TO APPLICATION)

I, ______________________, being duly authorized to execute this application onbehalf of the selected venue, certify that the answers and disclosures within thisapplication and its attachments to the best of my knowledge are true, accurateand complete.

Sworn and subscribed tobefore me this _______day of ____________, 20___.

_________________________________________A Notary Public of New Jersey


director/document/forms/questionnaires/pilot program application

PrintButton1: LicNo: RcptNo: IdNo: RcptDate: Oper: Check: CheckMoney: MO: MOMoney: InitialApp: A1A: A1B: A1C: A1D: A2A: A2B: A2C: A2CContinued: YesA3: NoA3: YesA4: NoA4: YesA5: NoA5: InformationA5: InformationA6: InformationA6Continued: YesA7: NoA7: YesA8: NoA8: YesA8A: NoA8A: YesA9: NoA9: Yes9AA: No9AA: A10A: Yes10B: No10B: Yes10BB: No10BB: VendorA11: AddressA11: PhoneA11: Yes12: No12: Yes12AA: No12AA: YesA13: noA13: A14Information: YesA15: NoA15: YesInformation15: Yes15: No15: Yes15A: nO15a: YES16: NO16: Yeseach16: Yesoneormore16: Notables16: Yes16C: YesA17: Noa17: A17Information: YesA18: NoA18: InformationA18: YesA19: NoA19: InformationA19: YesA20: NoA20: InformationA20: YesA21: NoA21: InformationA21: InformationA22: InformationA23: CertName: B1AInformation: B1bYes: B1bNo: B1cInformation: YesB1c: NoB1c: InformationB1d: B1eInformation: B1fMunicipality: B1gInformation: YesB1h: NoB1h: YesBli: NoBli: YesB1J: NoB1J: YesB1k: NoB1k: YesB2: NoB2: NoInformationB2: YesBB2: NoBB2: YesBB2Information: YesBB2InformationContinued: YesB3a: NoB3a: YesB3b: NoB3b: YesB4A: NoB4A: YesB4b: NoB4b: YesB4bb: NoB4bb: YesB4C: NoB4C: YesB5: NoB5: YesB5A: NoB5A: YesB5B: NoB5b: YesB5c: NoB5c: YesB5D: NoB5D: B5Information: YesB6: NoB6: B7Information: YesB8: NoB8: YesB9A: NoB9a: YesB9b: NoB9b: YesB10A: NoB10A: YesB10b: NoB10b: YesB10c: NoB10C: YesB10d: NoB10d: YesB11: NoB11: InformationB11: YesB12: NoB12: InformationB12: YesB13: NoB13: InformationB13: YesB14: InformationB14: YesB15: NoB15: Informationb15: B16Information: B17Information: YesB18: NoB18: YesInformationB18: YesB19: NoB19: InformationB19: B20Yes: B20No: B20Information: B21Yes: B21No: B21Information: YesB22: NoB22: B22Information: B23: TextField1B24:

ELECTRONIC WAGERING TERMINAL PILOT PROGRAM …agreement with a person or entity to conduct, manage...

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Transcript of ELECTRONIC WAGERING TERMINAL PILOT PROGRAM …agreement with a person or entity to conduct, manage...