HORSEMEN’S CHECK REQUEST FORM

DATE______________

NAME ON ACCOUNT_______________________________________________

ADDRESS__________________________________________________________

PHONE#______________________SS# or EIN ____________________________

W-9 For Payee on File (Circle one) YES NO

I authorize Blue Ribbon Downs to issue checks from my horsemen’s account upon my request by telephone or in person. YES NO

I authorize Blue Ribbon Downs to deduct 2006 nomination payments from my horsemen’s account. YES NO

I authorize Gene Wilson Photography to deduct cost of requested win pictures from my account in 2006. YES NO

I authorize a deduction from my horsemen’s account for any video tapes ordered.

YES NO

SIGNATURE OF ACCOUNT HOLDER ____________________________________

RETURN FORM TO: HORSEMSN’S BOOKKEEPER

BLUE RIBBON DOWNS

P.O. BOX 489

SALLISAW, OK. 74955

OR FAX TO: 918-775-6508