Any situation not covered by the rules of this Commission shall be referred to the Commission for disposition.

SWORN STATEMENT OF COMPLAINT

… … …
Name of ComplainantAddressCityTel. No.

… … …
Name of LicenseeAddressCityTel. No.

State Harness Racing Commission
Harrisburg, Pennsylvania
COMMONWEALTH OF PENNSYLVANIA
COUNTY } ss:
, being
(Name of Complainant)
first duly sworn deposes and says that
(Write in a brief

statement of the act complained of.)

Complainant

Sworn to and subscribed before me this day of , 19

Notary Public

WITNESSES
… …
NameAddressTele. No.
… …
NameAddressTele. No.
… …
NameAddressTele. No.

Mail original complaint, with two additional copies.
Type or write complaint clearly.
State facts briefly and clearly.
Name witnesses who can support your statements.
Enclose a Photostatic copy of each document to which this complaint refers.

CORPORATE RESOLUTION OF WAIVER

PENNSYLVANIA STATE HARNESS
RACING COMMISSION
HARRISBURG, PENNSYLVANIA
WHEREAS, it is the desire of

to waive the hearing fixed in Citation No. , to admit the charges therein contained and to authorize the Pennsylvania Harness Commission to enter a final order without hearing thereon,
THEREFORE, be it resolved that such a waiver be filed with the Pennsylvania Harness Racing Commission and that
… …and
Name of OfficerTitle
…
Name of OfficerTitle
be authorized and either or both are hereby authorized to execute the necessary documents as may be required by the Pennsylvania State Harness Racing Commission.
(Corporate Seal)*
*If no seal, have resolution sworn to before a Notary Public or Justice of the Peace.
I hereby certify that the foregoing is a true and correct copy of the Resolution adopted by
Name of

Corporation or Organization
at a regular or special meeting held on the
day of , 19 .

Secretary

PENNSYLVANIA HARNESS RACING COMMISSION
HARRISBURG, PENNSYLVANIA
WE
I do hereby acknowledge receipt of Citation No.

, and do waive the hearing fixed therein, subject to the approval of the Commission. All the charges averred in the citation are admitted and you are authorized without hearing to enter a final order.
…
WitnessSignature of Licensee

Date

THIS CERTIFICATE MUST ACCOMPANY THE HORSE DESCRIBED FOR ADMITTANCE TO A PENNSYLVANIA PARA-MUTUEL HARNESS RACING TRACK.

… … …
Name of HorseTattoo NumberAgeSex
…
Owner’s NameTrainer’s Name

I hereby certify that I have examined the above described horse on

and have found no clinical evidence of infectious, (date)
contagious, or transmissible disease and that it was afebrile and free of ectoparasites at the time of this examination. To the best of my knowledge this horse has not been exposed to other horses with any infectious, contagious, or transmissible diseases within the past two weeks.
Horse’s Temperature
At Time of Examination

Veterinarian’s Signature

Veterinarian’s State License Number Address Date Issued

APPENDIX A

Appendix A (Continued)

APPENDIX B

APPENDIX B (Continued)WAIVER, ADMISSION AND AUTHORIZATION

APPENDIX CCOMMONWEALTH OF PENNSLVANIASTATE HARNESS RACING COMMISSION2301 North Cameron StreetHarrisburg, PennsylvaniaVETERINARY HEALTH CERTIFICATEFOR STANDARDBRED HORSE