Retailer Application Form Please complete all fields within the Lottery Retailer Application. Applications are reviewed by the Retailer Review Committee. Type of Business(Required) Sole Owner Two or more partners National or Regional Retail Chain This field is hidden when viewing the formBusiness InformationBusiness Information Applicant Name(Required)Applicant Relation to Business(Required) General Manager Store Manager Owner Shareholder Partner Other Business Name(Required)Information Services Corp Entity Number(Required)Business Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) This field is hidden when viewing the formPROPRIETORSHIP: Sole Owner InformationOwner Information Owner Name(Required)Position/Title(Required)Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) This field is hidden when viewing the formCORPORATE: Corporate/Head Office InformationCorporate/Head Office Information Signing Authority Name(Required)(Person responsible for lottery portfolio with in corporate)Position/Title(Required)Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) This field is hidden when viewing the formPARTNERSHIP: Stakeholders/Owners InformationPartners – Stakeholder/Owner Information List all individuals with at least a 20 per cent stake in the company. Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) This field is hidden when viewing the formRetail Location InformationRetail Location Information Retail Location Name(Required)Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Same as mailing address Street Address same as mailing address Street Address or Legal Land Description(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Hours of Business(Required)DayOpen (a.m.)Close (p.m.) Add Remove Add Remove Add Remove Add Remove Add Remove Add Remove Add RemoveOn-site manager responsible for lottery(Required)NamePhoneEmail Add RemoveThe store location is:(Required) Owned Leased Lease Landlord Name(Required)Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) What products or other services are available at the retail location (Ex. Canada Post, Amazon outlet)?(Required)What is the estimated or current foot traffic in the retail location?(Required)What other businesses or services are around your retail location?(Required)Upload photos of your business. Photos must include: Exterior of building Front counter or place lottery would go (photos must show space for lottery equipment) Entrance to store General set up of store (Ex. shelves, etc.) Upload photos(Required) Drop files here or Select files Max. file size: 32 MB. This field is hidden when viewing the formDeclarationDeclaration Declaration(Required) By submitting this application, I certify that there are not misrepresentations or falsifications in the information stated in the application.