Revised May 2015

Coin Operated Amusement Machine Application

PART 1 - Business Information GEORGIA LOTTERY CORPORATION P.O. Box 56927 Atlanta, GA 30343 CLASS B LOCATION LICENSE ID#:
1-800-746-8546 - OPTION #4 - Retailer Contracts Administration

1. Corporate or legal name:

2. Type of Ownership: Sole Proprietor Partnership Corporation Non-Profit

LLC (Corporation) LLC (Partnership) Other(specify):

3. Store Name or DBA Name:

4. Business Address: 5. Mailing Address:

Address Line 1: Address Line 1:
Address Line 2: Address Line 2:
City: State: Zip Code:
City: State: Zip Code:
County: Fax Number:
Business Telephone Number: 6. Georgia State Tax Identifier Number:

7. Georgia Alcohol License Number: 8. Georgia Sales Tax Number:

9. Federal Employer Identification Number(EIN)/SS Number: 10. Withholding Tax Number:

11. List each owner, shareholder, member and officer of the Business. EACH LISTED INDIVIDUAL MUST COMPLETE PART 2 OF THIS FORM.

a. Name: % of Ownership: f. Name: % of Ownership:

b. Name: % of Ownership: g. Name: % of Ownership:

c. Name: % of Ownership: h. Name: % of Ownership:

d. Name: % of Ownership: i. Name: % of Ownership:

e. Name: % of Ownership: j. Name: % of Ownership:

12. (OPTIONAL) Is Business Ownership more than 50% of a minority race? Yes No

If Yes, Specify: African American Native American Asian Hispanic Other (specify):

13. Business Contacts: Name Title/Function Cell Phone #

a.

b.

14. Is this business a Georgia Lottery retailer? Yes No If Yes, enter 6 digit retailer number: