Pennsylvania Horsemen's Benevolent and Protective Association

I hereby appoint the Pennsylvania Horsemen's Benevolent and Protective Association, Inc. to act as my sole and exclusive agent and representative for the purpose of negotiation and executing, or refusing to execute, with Thoroughbred race tracks in Pennsylvania any and all contracts and agreements relating to Thoroughbred racing in the state. By this appointment, I hereby revoke any and all previous authorities given by me for similar purposes.

PA HBPA Membership Form

First Name *

Last Name *

Address *

Address

City

State/Province

Zip/Postal

Email *

Phone *

Stable, Corporation, Syndicate or Farm (if applicable) (as appears on program) *

Managing Partner *

Check One *

Owner

Trainer

Owner/Trainer

PARC License # *

Signature *

Clear

Date *

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Consent *

I consent to having PAHBPA collect my details via this form

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