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:_________