Application for Jockey's License APPLICATION Please enable JavaScript in your browser to complete this form.General Information Name *FirstLastAddress *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Date of BirthMinimum Riding Weight (lbs.)Insurance Information Name of Insurance CarrierPolicy Expiration DatePlease attach a copy of your current insurance Identification Card naming you as the insured. Click or drag a file to this area to upload. Emergency Contact Info Emergency Contact (Name)Emergency Contact (Phone Number)All jockeys must have a baseline ImPACT test on file with the NSA office, renewed every 3 years.Medical Information Blood TypeAllergiesOther Medical Information (optional)Background Information Do you have any criminal charges pending, or have you ever been convicted of a crime?NoYesIf so, give place, date, crime charged, and dispositionHave you ever had a license denied, suspended or revoked?NoYesIf so, please provide detailsHave you ever been suspended by the Stewards of any racing jurisdiction?NoYesIf so, please provide details Licensing ClassificationsThe NSA issues unrestricted licenses, which permit the licensee to compete in all races sanctioned by the NSA, as well as licenses restricted to training flat races (“Flat Races”) only, or flat races and timber or hurdle races only. By checking the appropriate box(s) below, you may apply for an unrestricted license, or a license restricted to one or more categories, but the determination as to which license will be issued to you will be made by the Stewards Advisory Committee based upon your background and experience in riding over different courses. All successful applicants will be permitted to ride in flat races. In order to compete in hurdle and timber races, an applicant must demonstrate the ability to jump fences and to compete in hurdle races, the ability to do so at speed. During the period in which a license is valid, a jockey may request that his/her license be modified to permit him/her to compete in one or more additional categories of races by request to the Stewards Advisory Committee and submitting information showing his/her ability to compete satisfactorily in the desired race category.I request the issuance of:Unrestricted LicenseFlat License OnlyFlat License & Hurdle License OnlyTimber License Only Amateur DeclarationThis section to be completed if you are applying for an Amateur License and declare your intention to compete for the year specified as an Amateur Jockey. By signing this section and completing the appropriate section(s) below, you certify that you are eligible and willing to compete as an amateur jockey under the following conditions: 1.) You have not been licensed and/or paid as a professional steeplechase jockey for the prior two (2) years, or as a professional flat racing jockey for the prior five (5) years; 2.) You agree not to accept compensation or remuneration for riding in races during the current season.DateSignature Clear Signature Jockey ExperienceIf you are currently licensed by another Turf Authority, you must enclose a certificate of clearance from that Turf Authority with this application. Required Equipment: All jockeys, when riding in a NSA sanctioned race, are required to wear the following: (1) An “approved” safety helmet, which is defined as one which carries an SEI label certifying that it conforms to ASTM standard #1163; or as approved by the British Horseracing Authority (EN 1384, PAS 015); (2) A body protector vest; (3) A medical identification tag, which is available from the Clerk of Scales. If no form of license has been held for three years, the applicant must complete the Qualification for Inexperienced Jockeys and submit with supporting letters in order to ride in races at NSA sanctioned race meets. Qualification for Inexperienced Jockeys • Complete the following NSA Inexperienced Jockey Information questionnaire. • Submit two letters from NSA-licensed trainers attesting to the jockey’s ability (First-time licensees only). Letters must indicate whether the jockey is qualified to ride in a race on the flat only, flat and timber only, or flat and hurdles only. • All Inexperienced Jockey license applications and letters of endorsement are subject to the review of the NSA Stewards Advisory Committee and granted licensees may serve a probation period.Have you held a jockey’s license previously?NoYesIf yes, please give details, including years licensed, type of racing involved, and the racing jurisdiction.Number of career rides, under rules, to date *( Hurdle, Timber, Flat)Number of career winners, under rules, to date(Hurdle, Timber, Flat)Are you retained by an owner or trainer to ride his/her horses?YesNoIf yes, please give the name of the person(s) with whom you have an agreementCertificate of Clearance Click or drag a file to this area to upload. Upload if you are licensed by another Turf Authority. NSA Inexperienced Jockey Information(Please complete if you have been licensed for three years or less)Are you presently, or have you in the past, “ridden out” for a licensed NSA trainer?NoYesType of Riding:JoggingGallopingWorkingAll Types of RidingTrainer's NameHave you ever “schooled in company”?YesNoHow many times?Once5-10More than 10Have you ever “schooled in company” over NSA National Fences?YesNoHow many times?Once5-10More than 10At what speed?SlowFastRacing SpeedHave you ever “schooled in company” over Timber Fences?YesNoHow many times?Once5-10More than 10At What Speed?SlowFastRacing SpeedHave you ever ridden in point-to-point races?YesNoIf yes, where and when?Indicate number of races ridden:(For Flat, Hurdle and Timber races - list a number for each)Agreement & SignatureConstentI consent to the terms listed on this page and website.I consent to the release of any medical information pertaining to any accident or injury sustained in the course of my duties as a licensed jockey to the National Steeplechase Association and/or its appointed medical designates. I understand that this information will be used only for documentation purposes and to facilitate appropriate medical care. By my signature hereto, I confirm that I have read this application for a license in its entirety, I understand it, and I agree to be governed by it, and I expressly agree to abide by the insurance requirements that are a condition precedent to the grant of my license.Signature Clear Signature Annual FeePrice: $250.00Submit Application & Pay NSA Membership Support Jump Racing in America and Join the NSA By becoming a member of the National Steeplechase Association, you can help support steeplechasing in America. The NSA offers three unique membership options (Historian, Patron and Member), each with exclusive benefits. To learn more or join the National Steeplechase Association, click the button below. JOIN NOW