RETAILER APPLICATION FOR A CERTIFICATE OF AUTHORITY TO SELL LOTTERY PRODUCTS

Transcription

1 RETAILER APPLICATION FOR A CERTIFICATE OF AUTHORITY TO SELL LOTTERY PRODUCTS OFFICE USE ONLY Retailer. Chain. Region/LSR. INSTRUCTIONS: The submission of Retailer Application for Certificate of Authority to sell Lottery products does not guarantee that a certificate of authority will be issued. The Applicant bears the burden of demonstrating that it is eligible to receive or hold a certificate of authority and must continue to meet all eligibility conditions or restrictions relating to possession of a certificate of authority after issuance. The information provided below will be used to verify eligibility to be a Lottery Retailer. If any required section is not completed, the application will not be processed. DIRECTIONS: 1) Please fill out all the information below. PLEASE TYPE OR PRINT IN BLUE OR BLACK INK. 2) Be sure to attach all necessary documentation and a check for the application fee. 3) After completing and signing, please deliver to: Hoosier Lottery Licensing 201 S. Capitol Ave. Suite 1100 Indianapolis, IN (317) SECTION 1 - BUSINESS INFORMATION Legal Name: D/B/A or Other Names (if any): Corporate Address: Contact Information: Corporate Contact Person: Title: Telephone.: Cell phone.: Address: Please attach a valid Certificate of Existence or Certificate of Authorization from the Indiana Secretary of State indicating that the Applicant is registered and duly qualified to do business in Indiana. See for more information. Organization (check one): Sole Proprietorship Partnership Corporation Limited Liability Company(L.L.C.) nprofit Corporation Other (please specifiy): 01. Grocery Store/Market 04. General Merchandise 07. Liquor Store Type of (check one): 02.Convenience Store w/ Gas 05. Tobacco Store 08. Restaurant/Bar/Lounge 03.Convenience Store w/o Gas 06. Drug Store 09. Other (please specify below): Revised April

2 SECTION 2 - TAX INFORMATION Federal Taxpayer ID.: Tax Identification Numbers: Indiana Taxpayer ID.: t-for-profit ID.(if applicable): - Please enter the taxpayer identification numbers assigned by the Internal Revenue Service and Indiana Department of Revenue in the boxes above. - If Applicant operates as a sole proprietorship, please provide the proprietor s Social Security Number if no other tax identification number has been assigned. Please attach a copy of a Registered Retail Merchant Certificate issued by the Indiana Department of Revenue to the Application. See for more information. ON 2 TAX INFORMATION SECTION 3 - SALES LOCATION INFORMATION Sales Location Physical Address: Mailing Address: Store Contact: - Please provide the contact and address information of the business location where you propose to sell lottery tickets, if different from above. - If the application is for more than one selling location, please provide the following information for each additional location in an attachment Store Name (if different from Legal Name above): Address ( P.O. Boxes): Address ( if different from above): Store Manager/Contact: Title: Telephone.: Cell phone.: Address: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours: Type of Games: Open Close Select the type of games to be sold at this location from the options below (select all that apply): Scratch-off Games Draw Games Pull-tab Games Revised April

3 SECTION 4 - PRINCIPAL INFORMATION For purposes of a criminal background check necessary for determining eligibility, please provide the information requested below on the following individual: - If a sole proprietorship, the sole proprietor. - If a partnership, the managing partner. - If a Limited Liability Company (LLC), the managing member. - If a corporation or other entity, the chief executive officer or similar top executive officer. Last Name: First Name: M.I. Maiden Name: Home Address: State: Zip Code: Title: Birth Date (MM/DD/YYYY): Gender: M F First 5 digits of Social Security.: - - X X X X SECTION 5 - BACKGROUND QUESTIONAIRE - Please respond to the following questions. If you answer yes to any of the questions, please provide the details on a separate sheet of paper, include your signature and the date, and attach it to this application. - Please note that, depending on the circumstances, a yes response will not necessarily disqualify you from obtaining a retailer contract. Has the Applicant or any member, partner, or corporate officer of the Applicant ever previously applied for or entered into a Hoosier Lottery Retailer Contract? (If yes, please provide details including the business name and retailer number.) Is the Applicant a department, agency, commission, or officer of the state or a political subdivision of the state or an entity that performs an essential governmental function? Has the Applicant, any member, partner, or corporate officer of the Applicant, or any agent of the Applicant, who participates in the management or sales of Lottery tickets, been convicted of, or entered a plea of guilty or nolo contendere to, a felony committed in the preceding ten (10) years, regardless of adjudication? (If yes, please provide details and information that include the name of the individuals involved, the nature, jurisdiction, and date of the offense, date of conviction, and dispositions and any orders of the court.) Is the Applicant or any member, partner, director, or corporate officer of the Applicant a director, officer, or employee of a Hoosier Lottery major procurement vendor? (For example, Scientific Games International Inc. and G-Tech Corp. are major procurement vendors of the Hoosier Lottery) Is the Applicant or any member, partner, director, or corporate officer of the Applicant related to any employee or commission of the State Lottery Commission as husband, wife or child? Has the Applicant filed for bankruptcy, been place into receivership, defaulted on a loan obligation, or filed for court protection from creditors in the last seven (7) years? (If yes, please provide details including the date, jurisdiction, and cause number, if any.) Revised April

4 SECTION 6- CERTIFICATIONS Please read each statement below and indicate an understanding and acceptance by having your authorized representative initial each in the column provided. Applicant understands and agrees that it must comply with all requests for information, documents, or other materials that may be reasonably necessary to determine the eligibility of the Applicant to receive a certificate of authority. Failure to provide any information may result in the application not being processed. It is understood and agreed that the Applicant is under a continuing duty to disclose any material change in the information provided to the Indiana State Lottery Commission. Any misrepresentation or omission made by the Applicant may be grounds for denial of the application or revocation or suspension of a certificate of authority already held by the Applicant. Initials Applicant understands and agrees that, if a certificate of authority is issued, it is bound by and must comply with the law, rules, regulations, and directions promulgated by the Indiana State Lottery Commission. Applicant agrees that, if issued a certificate of authority, it will not engage exclusively in the business of selling lottery tickets. Applicant certifies that any and all of the retail locations specified herein are in compliance with the requirements outlined by Title III of the federal Americans with Disabilities Act, excepting only those conditions that are separately and specifically described in a document prepared by Applicant and attached hereto. Applicant understands and agrees that a certificate of authority issued hereunder, if any, is non-transferable. Applicant understands and agrees that a change in ownership or reorganization of the Applicant must be reported to the Indiana State Lottery Commission at least thirty (30) days in advance of such occurrence. Applicant understands and agrees that, if a certificate of authority is issued and a retailer contract executed, (1) the Applicant; (2) an employee or officer of the Applicant who participates in the management or sales of Lottery tickets; or (3) a relative living in the same household with an employee or officer who participates in the management or sales of Lottery tickets, may not purchase a lottery ticket at the premises where the Applicant, its employee or officer participates in the management or sale of Lottery tickets. SECTION 7- APPLICATION FEES Please complete the following by multiplying the number of locations by the appropriate Application Fee amount (depending on the products to be sold at each location) to determine the total non-refundable Application Fee owed. Number of Locations X $100 [If selling Draw AND Instant Games (Scratch off and/or Pull-tabs)] = Application Fee Owed Number of Locations X $50 [If selling Instant Games (Scratch off and/or Pull-tabs) Only] = Application Fee Owed Application Fees are non-refundable. Make cashier s check, personal check, or money order payable to: Hoosier Lottery. HOW DID YOU HEAR ABOUT THE HOOSIER LOTTERY Please check one: I contacted the Hoosier Lottery I was contacted by: Revised April

5 AUTHORIZED SIGNATURE I hereby certify that I am the duly authorized representative of the Applicant with the power to sign any and all documents, as may be required by the Indiana State Lottery Commission. Under penalty of perjury, Applicant certifies that the information provided herein is true and complete to the best of its knowledge and belief and is provided as an inducement to the Lottery to enter into a Retailer Contract. Applicant authorizes the Lottery to conduct investigations into the financial and credit records, criminal history, and any other matter of the Applicant and its agents, which may be material to verifying the authenticity of any statement made herein. Applicant further authorizes the Indiana Department of Revenue to provide the Lottery with business and individual tax clearance statements. Authorized Representative Signature: Signature of authorized corporate officer, partner, or owner Title Date tary Certificate and Acknowledgement: State of SS: (OFFICIAL SEAL) County of Subscribed and Sworn before me this day of 20 tary Public My Commission Expires Revised April