11. List each owner, shareholder, member and offcer of the Business.

EACH LISTED INDIVIDUAL MUST COMPLETE PART 2 OF THIS FORM.

a. Name: % of Ownership:
b. Name: % of Ownership:
c. Name: % of Ownership:
d. Name: % of Ownership:
e. Name: % of Ownership:
f. Name: % of Ownership:
g. Name: % of Ownership:
h. Name: % of Ownership:
i. Name: % of Ownership:
j. Name: % of Ownership:
7. Georgia Alcohol License Number: 8. Georgia Sales Tax Number:
4. Business Address:
Address Line 1:
Address Line 2:
City: State: Zip Code:
County: Fax Number:
Business Telephone Number:
6. Georgia State Tax Identifer Number:
Coin Operated Amusement Machine Application
GEORGIA LOTTERY CORPORATION P.O. Box 56927 Atlanta, GA 30343
1-800-746-8546 - OPTION #4 - Retailer Contracts Administration
PART 1 - Business Information
Revised May 2014
CLASS B LOCATION LICENSE ID#:
1. Corporate or legal name:
2. Type of Ownership: Sole Proprietor Partnership Corporation Non-Proft
LLC (Corporation) LLC (Partnership) Other(specify):
3. Store Name or DBA Name:
5. Mailing Address:
Address Line 1:
Address Line 2:
City: State: Zip Code:
9. Federal Employer Identifcation Number(EIN)/SS Number: 10. Withholding Tax Number:
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:
15. Business Information Prepared by:

Name Title Date