Application for Ohio TAB Account

Instructions: Please print the following form, complete it, and mail original to:

Ohio TAB
P.O BOX 850
Grove City, Ohio 43123

Please open a telephone account for me.

_____________________________________________________________________________
Name: Last                                                            First                                   Middle

_____________________________________________________________________________
Mailing Address: Number and Street                      City                             State           Zip

_____________________________________________________________________________
Area Code         Number                           Social Security                      Desired Code Word
                                                                                                         (Any Combination up to 10 letters)

My Check Payable to Ohio TAB in the amount of $______________ is enclosed as initial deposit.

I certify that I am a United States resident, 18 years of age or older, and I am not an approved Licensed Racing Official of any race track.

_____________________________________
   (Signature)

The service is open only to legal U.S. residents. Ohio TAB does not accept accounts from residents of the following states: Alaska, Arizona, Colorado, Georgia, Hawaii, Mississippi, Missouri, Nevada, New Jersey, North Carolina, South Carolina or Utah, nor from Puerto Rico or the Virgin Islands. List is subject to change if states' policies change.

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