AUTHORIZED AGENT FORM Date:_____________________ I have this day appointed_________________________________________ whose address is_______________________________________________ as an agent to act for me for the year 2___ for matters pertaining to the racing of horses, as described below, at race meetings licensed by the Virginia Racing Commission. Owner:___________________________________ Address:__________________________________ City, State, Zip:____________________________ Owner’s Signature:_________________________________________ Authorized Agent May: o Claim Horses in my (our) name o Buy, Sell or Transfer Horses without my written consent o Receive and endorse checks made payable to me (us) o Direct the transfer of money to my (our) account o Have checks payable to himself/herself from my (our) account State of ______________________ County or City of ______________ The foregoing instrument was acknowledged before me this ___________ day of ______, 20_____ by _____________________________________. _____________________________ Notary Public My Commission expires:_________