ROCHESTER FAIR ~ PURSE CHECK
REQUEST AUTHORIZATION FORM

Date:_______________________

ARE YOU ~    OWNER     TRAINER      DRIVER
PLEASE PRINT
Before your purse check can be mailed, or released  this form MUST be completed appropriately.

HORSES RACING
_________________ _________________ _________________
_________________ _________________ _________________
_________________ _________________ _________________
     
FIRST OWNER (you) _________________________________
TELEPHONE #______________________________________
SOCIAL SECURITY NUMBER __________________________
FEDERAL ID NUMBER _______________________________
PRESENT MAILING ADDRESS ___________________________________________________
CITY/ STATE / ZIP __________________________________
Write the names of any additional owners on the back complete with addresses.
Please answer the following questions:
1. Do you as the principal owner request that your purse check be mailed to your current mailing address?     YES     NO
 2. If NO where do you as the principal owner request your purse check be mailed?

NAME __________________________________________
ADDRESS_______________________________________
CITY/STATE/ZIP___________________________________

3. Do you request that your purse check be sent to someone else?  YES       NO

If YES, then you must complete the following:

I,___________________________ , hereby give authorization to have my purse check mailed to ________________________________ at the following address

NAME __________________________________________
ADDRESS_______________________________________
CITY/STATE/ZIP___________________________________

I understand that my check will not be mailed to me and that
it will be mailed to the person for which I have given authorization