W. Va. Code R. agency 178, tit. 178, ser. 178-01, pt. 9, tbl. 178-1 C

Current through Register Vol. XLI, No. 50, December 13, 2024

Table 178-1 C - REQUEST TO WEAR ADVERTISING AND PROMOTIONAL MATERIAL

DATE OF ENTRY __________________

DATE OF RACE __________________

RACETRACK: [] CHARLES TOWN [] MOUNTAINEER

RACE NUMBER __________________

NAME OF RACE (STAKES IF APPLICABLE) __________________

DESCRIPTION OF MATERIAL TO BE WORN: (Use a separate sheet if necessary)

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

NAME OF ADVERTISER, PROMOTIONAL BRAND OR SPONSOR:

_________________________________________________________________________

NAME OF JOCKEY WEARING THE MATERIAL: _________________________

_______________________________ ________________________

Signature of the Jockey or Agent Date

_______________________________

Title (if applicable)

APPROVAL OF OWNER OR DULY AUTHORIZED AGENT

_____________________________ ______________________

Signature Date

_____________________________

Title

APPROVAL OF LICENSED RACING ASSOCIATION

_____________________________ ______________________

Signature Date

_____________________________

Title

APPROVAL OF THE STEWARDS

_____________________________ ______________________

Signature Date

_____________________________ ______________________

Signature Date

_____________________________ ______________________

Signature Date

W. Va. Code R. agency 178, tit. 178, ser. 178-01, pt. 9, tbl. 178-1 C