The Georgia Lottery Application form is a crucial document for businesses seeking to become authorized retailers of lottery tickets in Georgia. This form requires detailed information about the business and its owners, ensuring that all applicants meet the necessary qualifications. If you're ready to take the next step, fill out the application form by clicking the button below.
The Georgia Lottery Application form is a crucial document for businesses seeking to become authorized retailers of lottery tickets. This form encompasses several key sections, beginning with essential business information. Applicants must provide details about their business entity, including the legal name, business name, address, and contact information. A fee of $125 is required for each business location, with a partial refund available if the application is not approved. The form also requires personal information from each owner or principal, including identification verification and a notarized statement. Additionally, the application includes a section for electronic funds transfer authorization, ensuring that lottery proceeds are properly managed. Finally, a retailer contract must be completed, outlining the responsibilities and obligations of the retailer, including compliance with lottery rules and regulations. By carefully completing this application, businesses can take the first step towards participating in Georgia's lottery system.
GEORGIA LOTTERY CORPORATION
Instructions for Retailer Application Packet 1-800-746-8546 - OPTION #4 & then #7 - Retailer Contracts Administration
Revised 4/1/18
PART 1 - Business Information
PART 2 - Personal Information (Owner)
A Georgia Lottery Retailer application must be accompanied by a Cashier’s Check, Business Check or Money Order for $125 per business location. (In the event the application for a business location is not approved by the Georgia Lottery Corporation, $100 of the $125 will be refunded.)
This form must be completed for each owner, shareholder, member, and officer of the business. Make additional copies if necessary.
Lines 1 - 14 - List all information requested.
Line 1 - List the name of the entity which owns the business and files Income tax returns.
Line 2 - List the name of the business where tickets are to be sold.
Line 3 - 8 - List the business address, business telephone #, city, state, zip, & county
Lines 9 - 12 - List the mailing address, if different from #3 above: otherwise, please leave this blank.
Line 13 - List fax number, if applicable.
Line 14 - List each Principal of the Business. Please attach additional sheets as needed. EACH LISTED INDIVIDUAL MUST ALSO COMPLETE PART 2 OF THIS APPLICATION.
Line 15 - Complete, sign and have this statement notarized.
Line 16 - Business Contacts – Name, title, and phone number of the person(s) the Lottery should contact on all Lottery business.
Line 17 - COAM information - Complete all information requested for Coin Operated Amusement Machines.
Line 18 - Optional - If the majority ownership (more than 50%) of the business is held by a person or persons of a minority race, it is requested, but not mandatory, that this section be completed. Minority Business Ownership is defined in Georgia statutes as follows:
•For a proprietorship: A business owned by “an individual who is a member of a minority who reports as his personal income for
Georgia Income tax purposes the income of such business”; or
•For a partnership: “A partnership in which a majority of the ownership interest is owned by one or more members of a minority who report as their personal income for Georgia income tax purposes more than 50 percent of the income of the partnership”; or
•For a corporation: “A corporation organized under the laws of this state in which a majority of the common stock is owned by one or more members of a minority who report as their personal income for Georgia Income tax purposes more than 50 percent of the distributed earnings of the corporation.”
Line 19 - Business Hours - List business hours for Sunday through Saturday.
LOTTERY OFFICIAL TO COMPLETE ALL SHADED ENTRIES
Line 15 - If answering “yes” to any of these questions, please explain on a separate sheet and attach to this application.
Lines 16 - 21 - List all information requested.
Line 22 - Attach a copy of one of the following forms of identification (Driver's License, Georgia Identification Card, Identification Card issued by another state, U.S. Armed Forces Identification Card, U.S. Passport or U.S. Resident Alien Card).
Line 23 - Complete, sign and have this statement notarized.
PART 3 - Electronic Funds Transfer Authorization
Lines 2 - 4 - Obtain and list required licensing numbers from the Georgia Department of Revenue (State Tax Identifier, Sales Tax, & Alcohol).
Line 5 - The Federal Employers ID Number (FEIN) must be listed for partnerships and corporations. Sole proprietors must list the social security number only.
Line 6 - List all information requested and sign the authorization.
Line 7 - Must be completed and signed by Depository Institution Representative.
This verifies the establishment of an account “In Trust for the Georgia Lottery Corporation.” Attached is a letter to provide to your Bank Representative which provides an example of the account title requirements.
PART 4 - E-Verify Affidavit
The completed/executed affidavit is required of ALL GLC Retailer
Applicants. See the E-Verify Affidavit Instructions Letter for
important information regarding the completion of this affidavit.
PART 5 - Retailer Contract
A Contract must also be completed by each member of an LLC or Partnership. Make additional copies if necessary. Complete and sign page 2 of the Retailer Contract.
Business Trade Styles
Restaurant/Truck Stop
Auto Supply
Convenience
Home Improvement
Not Classified
Restaurants (Non-Fast Food)
Bar/Lounge/ Tavern
Convenience/Gas
Hotels & Other Lodging
Other Non-retail
Service/Gas Station
Bowling Center
Discount Department Stores
Independent/Grocery Store
Other Retail
Stationery/Gift/Newsstand
Check Cashing
Drug Store/Pharmacy
Major Supermarket Stores
Package Store
Value Stores
Coffee Houses
Fraternal Organizations
Mall Kiosk
Restaurant
Video Store
Retailer Application
P.O. Box 56486 • Atlanta, GA 30343 1-800-746-8546 - OPTION #4 & then #7 - Retailer Contracts Administration
Please submit completed application with $125 fee per business location
(Cashier’s Check, Business Check, or Money Order only).
1 of 4
PLEASE PRINT
Lottery Retailer ID#:
1.Corporate or legal name (List the name of the legal entity which owns the business and files income tax returns):
2.Store Name or d/b/a (list the name of the business where tickets are to be sold):
3.
Business Location:
(Street Number and Name of the location where lottery tickets are to be sold)
4. Business Telephone Number:
5.
City:
6. State:
7. Zip Code:
8. County:
9. Mailing Address (if different) (P.O. Box Number or Street Number and Name) :
10. City:
11. State:
12. Zip Code:
13. Fax Number:
14.List each owner, shareholder, member and officer of the Business (for example, sole proprietors, general partners, corporate officers, directors and shareholders). EACH LISTED INDIVIDUAL MUST COMPLETE PART 2 OF THIS FORM. Please attach additional sheets as needed:
a.
Name:
Percent of Ownership:
b.
c.
d.
15.Applicant certifies that the information contained on this form or otherwise submitted to the Georgia Lottery Corporation (“GLC”) in connection with this application to become a Retailer is true and correct in every respect. The undersigned certifies that he is duly authorized to act on behalf of the Retailer Applicant. Applicant understands, agrees, and consents that the GLC may make any and all investigations necessary in order to satisfy the GLC requirements for qualification of the Applicant as a GLC Retailer. Applicant hereby authorizes GLC to request criminal history record information, a credit report, or conduct any other investigation as may be necessary to process Applicant’s request to become a GLC Retailer.
Applicant authorizes GLC to share any such information, privileged, confidential or otherwise, necessary to consider its application to become a GLC
Retailer. Applicant further consents to allow GLC to use and share such information in all manner consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the relationship between Applicant and GLC. Applicant understands that providing inaccurate or misleading information is grounds for rejection of this application or cancellation of the Retailer Contract, and may subject the Applicant to the penalties set forth in O.C.G.A. §50-27-28.
Signature of Owner or Principal
Print or Type Name
Title
Date
NOTARY
STATE OF:
COUNTY OF:
SEAL
SWORN TO AND SUBSCRIBED BEFORE ME ON THIS
DAY OF
(MONTH)
(YEAR)
Notary Public Seal and Signature:
My Commission Expires:
HERE
Personal Identification (ID) is required to be presented to and verified by Notary Public. Type of ID:
ID Number:
16. Business Contacts (Persons Authorized to Conduct On-Site Lottery Transactions):
Name
Title/Function
Cell Phone #
17. Is this business location licensed for Coin Operated Amusement Machines (COAM)? ___Yes
___No
If Yes, provide the following:
# of Class A Machines:_________
# of Class B Machines:_________
COAM Location License #_________________________
COAM Master License # __________________________
18. (OPTIONAL) Is Business Ownership more than 50% of a minority race?
Yes
No
If yes, Specify: African American
Native American
Asian
Hispanic
Other (specify):
19. Business Hours:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Open
Close
To be completed by Lottery Representative
Business Trade Style: (see Instruction Sheet)
2 of 4
Make additional
P.O. Box 56486 • Atlanta, GA 30343
copies if necessary.
1-800-746-8546 - OPTION
#4 & then #7 - Retailer Contracts Administration
This form must be completed for each owner, shareholder, member, and officer of the business.
1. Type of Ownership:
Sole Proprietor Partnership
Corporation
Non-Profit
LLC (Corporation) LLC (Partnership)
Other(specify):
2.
First, Middle & Last Name of Owner or Principal (no initials):
M or F:
4. Place of Birth:
Title:
6.
Race:
7. Percent of Ownership:
8. Date of Birth:
9.
Home Street Address:
10. City/State/Zip Code:
11.
Home Phone Number:
12. Cell Phone Number:
13.
Social Security
Number:
14. E-mail Address:
(
)
15.
•Do you reside in the same
household as any officer or
employee of the Georgia Lottery Corporation?
•Are you a vendor, employee or agent of any vendor of the Georgia Lottery Corporation?
•Have you been convicted of a criminal offense related to the security or integrity of the lottery in this or any other jurisdiction? If yes,
where? and when?
•Have you been convicted of any illegal gambling activity, false statements, false swearing or perjury in this or any other jurisdiction or
convicted of any crime punishable by more than one year of imprisonment or a fine of more than $1,000.00 or both ? If yes, where?
and when?
•Are you delinquent in taxes, fees or other obligations owed to the State of Georgia?
•Have you filed bankruptcy in the last seven (7) years?
•Are you related to a COAM Class B Master Licensee?
Note: If you answered “Yes” to any of the above questions, please explain on a separate sheet and attach to this application.
16.List all other names you have used, including nicknames; if female, furnish 17. Citizenship
maiden names. If you have ever used any surnames other than your true name,
a. Present citizenship (Country):
during what period and what circumstances were these used? If you have ever legally
b. Citizenship acquired by:
Birth Marriage Naturalization
changed your name, give date, place, and court. (Attach additional page as needed):
c. Naturalization Certificate Number:
d. Date and place Naturalized:
e. Resident Alien Number:
18.
Height:
19. Weight:
20.
Hair Color:
21. Eye Color:
22.Attach a copy of one of the following forms of identification for each owner. The following is a list of acceptable forms of identification: Driver's License, Georgia Identification Card, Identification Card issued by another state, U.S. Armed Forces Identification Card, U.S. Passport, or U.S. Resident Alien Card.
23.CONSENT AND AUTHORIZATION FOR RELEASE OF PERSONAL BACKGROUND INFORMATION:
I hereby certify that the information contained on this form or otherwise submitted by me to the Georgia Lottery Corporation (“GLC”) in connection with this application to become a GLC Retailer is true and correct in every respect. I understand, agree and consent that GLC may make any and all investigations of my background in order to satisfy the GLC requirements for qualification of the Applicant as a GLC Retailer, which investigations may include, without limitation, criminal history record information, credit history records, tax records, public records and other official records, and the investigation generally of any other matter relating to the Applicant being a GLC Retailer. As a potential Retailer or current Retailer for the Georgia Lottery Corporation (“GLC”), or as an owner of same, I am required to furnish certain information for use in determining my qualifications. I hereby authorize GLC to request a credit report, conduct a criminal background investigation, or conduct any other investigation as may be necessary to process my Retailer Application to become a GLC Retailer. I authorize GLC to share any such information, privileged, confidential or otherwise, necessary to consider the application to become a GLC Retailer. I further consent to allow GLC to use and share such information in all manner consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the relationship between the Retailer Applicant and GLC. A photocopy of this release will be valid as an original thereof, even though said photocopy does not contain an original writing of my signature. This release will expire upon the final termination of my Retailer’s contractual obligations with the GLC.
Signature
Print Name
The foregoing authorization notwithstanding, for the limited purposes of initially qualifying a Georgia Lottery Retailer, the GLC will not order, as a routine business practice, credit reports or criminal record history reports for individuals owning 10% or less of the equity ownership interests in the Georgia Lottery Retailer applicant. The GLC does reserve the right in its sole discretion to order such reports in accordance with business exigencies.
3 of 4
1-800-746-8546 - OPTION #4 then #7 - Retailer Contracts Administration
PART 3 - Lottery Retailer Electronic Funds Transfer Authorization
1. Corporate or Legal Name (list the name of the legal entity which owns the business and files income tax returns):
2. Georgia State Tax Identifier Number (11
3. Georgia Alcohol License Number (if any, 7 digits):
4. Georgia Sales Tax Number (9
Service Business
Only
5.Federal Employers ID Number. 9 digit number used to file Federal business income tax return. (For Sole Proprietor use Social Security Number)
INSTRUCTIONS: The Retailer must establish a separate electronic funds transfer (EFT) bank account for the preservation and transfer of
lottery funds. The separate bank account must be specified “IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.” The Retailer’s depository institution must confirm the establishment of the Georgia Lottery Corporation Trust Account by signing in the space below.
6.RETAILER AUTHORIZATION: I (we) hereby authorize the Georgia Lottery Corporation to initiate debit and credit entries in any available and appropriate amount to my (our) account indicated below and authorize the depository named below to debit or credit the same to such account. I (we) hereby further authorize and direct the depository institution named below to release any information regarding such account, including, but not limited to, account balance information, payment history, and overdraft information to the Georgia Lottery Corporation upon request by an authorized representative of the Georgia Lottery Corporation. My (our) authorization is given in accordance with subsection
(e)(2) of Section 502 of the “Gramm-Leach-Bliley Act of 1999” (15 U.S.C.A. § 6802) and shall remain in effect until expressly revoked by me
(us) in writing. Any such revocation shall be deemed to have been properly given if sent by hand delivery, or by overnight courier, to such depository institution at the address set forth below. Such revocation shall be deemed to have been delivered on the date of delivery if by hand delivery or if by overnight courier, on the next business day following the deposit of such communication with the overnight courier.
Bank Account Name:
/“IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.”
Corporate or legal name of entity which owns the business and files income tax returns: (see attached example)
Bank Name (print):
Branch:
Bank Street Address:
State:
EFT Bank Route Transit Number:
EFT Bank Account Number:
Signature of Owner or Principal:
Date:
Printed Name of Owner or Principal:
THE SECTION BELOW MUST BE COMPLETED BY DEPOSITORY INSTITUTION (BANK)
7.DEPOSITORY INSTITUTION ACKNOWLEDGMENT: The above account has been established “IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.” We acknowledge that our customer, the Retailer, has directed us to provide information concerning the above referenced account to the Georgia Lottery Corporation upon request by an authorized representative of the Georgia Lottery Corporation. We further acknowledge that the Retailer has directed us to provide this information in accordance with subsection (e)(2) of Section 502 of the “Gramm- Leach-Bliley Act of 1999” (15 U.S.C.A. § 6802), and we will continue to provide such information as directed until receipt of Retailer’s written revocation in the manner set forth in Section 6 above.
Depository Institution Representative (print):
Telephone Number:
Signature of Depository Institution Representative:
4 of 4
Part 4 – Lottery Retailer E-Verify Affidavit
The GLC Retailer, signed below, confirms and verifies its compliance with Georgia law (See OCGA §13-10-91, as amended), and affirmatively states that the business (Sole Proprietor, Partnership, Corporation, Non-Profit, LLC Corporation, or LLC Partnership) which sells GLC lottery tickets: (check and complete #1 or #2 below)
Legal Business Name of Georgia Lottery Retailer/Applicant:
____1. Has registered with, is authorized to use, and uses the federal work authorization program commonly
known as E-Verify, or any subsequent replacement program. Furthermore, the undersigned retailer will continue to use the federal work authorization program throughout the contract period. Retailer hereby attests that its federal work authorization user identification number and date of authorization are as follows:
_______________________________________________
Federal Work Authorization User Identification Number
This number is at least 4 or more digits in length, does not contain letters and is NOT your Federal Employer Identification Number (FEIN).
Date of Authorization
OR
____2. Employs no employees, or otherwise does not fall within the requirements of OCGA §13-10-91.
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on _______________ DAY OF __________, 20 in _________________(city) _____________(state).
_________________________________________________________
Signature of Authorized Owner/Officer
____________________________________________________
Printed Name and Title of Authorized Owner/Officer
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF __________, 20___.
____________________________________________________________
NOTARY PUBLIC
My Commission Expires: ______________________________________
Completing the Georgia Lottery Application form is an essential step for those wishing to become a retailer. This process involves providing detailed information about your business and its owners. Once you have filled out the form correctly and submitted it along with the required fee, your application will be reviewed by the Georgia Lottery Corporation. If approved, you will be able to sell lottery tickets at your designated location.
The application fee to become a Georgia Lottery Retailer is $125 per business location. This fee must be submitted via Cashier’s Check, Business Check, or Money Order. If your application is not approved, you will receive a refund of $100 from the original fee.
In Part 1, you need to provide various details about your business, including:
Each owner, shareholder, or officer must provide a copy of one form of identification. Acceptable forms include:
If your application is denied, you will receive a refund of $100 from the initial application fee. The remaining $25 is non-refundable as it covers administrative costs associated with processing the application.
Completing the Georgia Lottery Application form can be a straightforward process, but several common mistakes can lead to delays or even rejection. Understanding these pitfalls can help applicants avoid unnecessary complications.
One frequent error is failing to provide accurate business information. Applicants often list the wrong business name or address, which can confuse the review process. The application requires the legal name of the entity that files income tax returns, and any discrepancies here can lead to significant issues. It's essential to double-check all details against official documents.
Another common mistake involves the incomplete listing of business owners or principals. Each individual listed must complete Part 2 of the application. Omitting a name or failing to provide the required ownership percentage can result in delays. Applicants should ensure that all owners are included and that their ownership stakes are clearly stated.
Additionally, applicants often neglect to attach the necessary identification. The form specifies that a copy of an acceptable form of ID must accompany the application. Failing to include this document can lead to immediate rejection. It’s important to review the list of acceptable IDs and ensure that the correct one is provided.
Another area where mistakes occur is in the notarization of signatures. The application requires that certain statements be notarized. If the applicant forgets this step or does not have the signature properly notarized, it can invalidate the application. It’s advisable to confirm that all signatures are completed and notarized before submission.
Moreover, applicants sometimes overlook the payment requirement. The application must be submitted with a cashier’s check, business check, or money order for $125. Not including the fee or providing the wrong payment method can halt the application process. Always ensure that the payment is attached and meets the specified requirements.
Lastly, applicants may misunderstand the business hours section. Providing inaccurate hours can lead to confusion regarding when the business operates. This information is important for the Lottery Corporation’s operational needs, so clarity and accuracy are key. Applicants should carefully review their business hours and ensure they are correctly listed.
The Georgia Lottery Application form is an essential document for those seeking to become a Georgia Lottery Retailer. To support the application process, several additional forms and documents are often required. Each plays a crucial role in ensuring compliance with the Georgia Lottery Corporation's regulations.
Completing these forms accurately and submitting them alongside the Georgia Lottery Application is vital for a successful application process. Each document serves to establish the legitimacy and readiness of the business to participate in the Georgia Lottery system.
Business License Application: Similar to the Georgia Lottery Application, a Business License Application requires detailed information about the business entity, including ownership details and business location. Both forms seek to verify the legitimacy and compliance of the business with local regulations.
Retailer Agreement: Like the Lottery Application, a Retailer Agreement outlines the responsibilities and obligations of the retailer. Both documents ensure that the retailer adheres to specific rules and regulations while conducting business.
Tax Registration Form: Both the Lottery Application and a Tax Registration Form require the submission of identification and business information. Each form serves to confirm the business’s tax obligations and compliance with state laws.
Vendor Registration Form: Similar in structure, a Vendor Registration Form collects information about the business and its owners. Both forms aim to establish a formal relationship between the business and a governing body, ensuring accountability.
Certificate of Authority Application: This application, like the Lottery Application, requires detailed business information and ownership disclosures. Both documents are designed to ensure that the business is authorized to operate within its designated scope.
Employment Application: An Employment Application shares similarities with the Lottery Application in that it collects personal and professional information about individuals associated with the business. Both documents are essential for establishing trust and verifying qualifications.
Partnership Agreement: Much like the Lottery Application, a Partnership Agreement outlines the roles and responsibilities of each partner. Both documents require comprehensive details about ownership and management structures.
Financial Disclosure Form: Similar to the Lottery Application, a Financial Disclosure Form seeks to gather personal and business financial information. Both documents are critical for assessing the financial integrity and stability of the business.
When filling out the Georgia Lottery Application form, consider the following guidelines:
Understanding the Georgia Lottery Application form is crucial for potential retailers. However, several misconceptions can create confusion. Here are seven common misunderstandings:
By clarifying these misconceptions, potential retailers can better navigate the application process and understand their responsibilities as lottery ticket sellers.
Key Takeaways for Filling Out the Georgia Lottery Application Form