Required Documents for COAM License Application

(Applicable only to Class B Masters and Locations with Class B Machines)

Document Checklist

All applicants for Coin Operated Amusement Machine (COAM) Class B Masters and Locations
with Class B Machines are required to complete and submit the documents listed below. Please
utilize these instructions to prepare and mail the documents required to complete your COAM
License application.

These documents must be submitted by each owner (top 10 primary owners, officers, partners,
members, and shareholders):

1. Coin Operated Amusement Machine Application: review the Part 1 Business
Information page and each owners specific Part 2 - Personal Information page of the
attached application and sign on the designated signature line. Each owners signed Part
2- Personal Information page must benotarized.

2. Affidavit: A signed and sworn (notarized) Verification of Lawful Presence Within the
United States Affidavit verifying each owners lawful presence in the United States.

How to Fill Out the Affidavit:

a) Legal Business Name Prefilled as entered in the COAM website.
b) License Number Prefilled by the COAM website.
c) Citizenship Status Check any one of the three options that best describes your
citizenship status.
d) If you are a qualified alien or non-immigrant under the Federal Immigration and
Nationality Act, provide your alien number issued by the Department of Homeland
Security or other federal immigration agency.
e) Provide the type of Secure and Verifiable Document that you will submit with your
affidavit. Attached is a complete list of acceptable Secure and Verifiable Documents.

3. Secure and Verifiable Document: A legible front and back copy of each owners
applicable Secure and Verifiable Document. Attached is a complete list of acceptable
Secure and Verifiable Documents.

Purpose of the Affidavit: Georgia Law (O.C.G.A. 50-36-1, et seq.) requires the GLC to verify the
lawful presence within the United States of all applicants for licenses, and, when necessary, utilize
the Systematic Alien Verification for Entitlements (SAVE) Program to confirm an applicants lawful
presence in the United States. The SAVE Program is an intergovernmental information-sharing
initiative designed to assist Federal, State government agencies and non-governmental agencies,
such as licensing bureaus, in determining an individuals immigration status. The information
provided by SAVE will ensure that only entitled applicants will be granted the license for which they
applied. SAVE only provides the immigration status of these individuals and does not make
determinations or recommendations regarding a non-citizens eligibility for the license.


Page 2
Required License Application Documents



4. Photo Identification: Attach a copy of one of the following forms of photo identification to
the printed version of their application:

Drivers License
Identification Card issued by Georgia or another state
U.S. Armed Forces Identification Card
U.S. Passport or Resident Alien Card


5. Explanations: Each applicant (primary top 10) that answered yes to any of the questions
listed on the Part 2 - Personal Information page of their application, should provide
explanations on a separate sheet of paper and attach to the printed version of their
application.


6. Proof of Divested Interest: If a Master Class B applicant had interests in any business
operating as a COAM manufacturer, distributor, location owner or location operator within
the past 5 years and divested their interest in the location, written proof of the closing must
be provided (to include date of sale, name, address and telephone number of the purchaser).
Copies of this written proof must be attached to their printed version of the application.


Note: Your application cannot be renewed or approved until all the documents are completed
and returned to the Georgia Lottery.

For Class B Masters only: If a Verification of Lawful Presence Within the United States
Affidavit and Secure and Verifiable Document have already been mailed to the Georgia
Lottery for each owner, it is not necessary to re-submit.



Mail the documents listed above for each of the primary (top ten) owners, officers, partners,
members and shareholders to the following address:


Georgia Lottery Corporation
COAM Department
P.O. Box 56927
Atlanta, GA 30343





Acceptable Secure and Verifiable Documents
Under O.C.G.A. 50-36-2


An unexpired United States passport or passport card
An unexpired United States military identification card
An unexpired Drivers license or Identification Card issued by one of the United States, District of
Columbia, Commonwealth of Puerto Rico, Guam, Commonwealth of the Northern Marianas Islands,
United States Virgin Island, American Samoa, or Swain Islands, provided that it contains a
photograph of the bearer or lists sufficient identifying information regarding the bearer, such as
name, date of birth, gender, height, eye color, and address to enable the identification of the bearer.
An unexpired Tribal identification card of a federally recognized Native American tribe, provided
that it contains a photograph of the bearer or lists sufficient identifying information regarding the
bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification
of the bearer. A listing of federally recognized Native American tribes may be found at:
http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/ ind ex.htm
An unexpired United States Permanent Resident Card or Alien Registration Receipt Card
An unexpired Employment Authorization Document that contains a photograph of the bearer
An unexpired Passport issued by a foreign government, provided that such passport is accompanied
by a United States Department of Homeland Security (DHS) Form I-94, DHS Form I-94A, DHS
Form I-94W, or other federal from specifying an individuals lawful immigration status or other
proof of lawful presence under federal immigration law.
An unexpired Merchant Mariner Document or Merchant Mariner Credential issued by the United
States Coast Guard.
An unexpired Free and Secure Trade (FAST) card.
An unexpired NEXUS card.
An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card.
An unexpired Drivers license issued by a Canadian government authority.
Certificate of Citizenship issued by the United States Department of Citizenship and Immigration
Services (USCIS) (Form N-550 or Form N-570)
Certificate of Naturalization issued by the United States Department of Citizenship and
Immigration Services (USCIS) (Form N-550 or Form N-570)
Certification of Report of Birth issued by the United States Department of State (Form DS-1350)
Certification of Birth Abroad issued by the United States Department of State (Form FS-545)
Consular Report of Birth Abroad issued by the United States Department of State (Form FS-240)
An original or certified copy of a birth certificate issued by a State, county, municipal authority, or
territory of the United States bearing an official seal
In addition to the documents listed herein, if, in administering a public benefit or program, an agency
is required by federal law to accept a document or other form of identification for proof
of or documentation of identity, that document or other form of identification will be deemed a
secure and verifiable document solely for that particular program or administration of that particular
public benefit.

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

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. Has the business entity had a gambling license in any state or jurisdication? Yes No If Yes, provide the following:
State or Jurisdication that issued license: What year(s) the license was held:
a. Name: % of Ownership:
b. Name: % of Ownership:
c. Name: % of Ownership:
d. Name: % of Ownership:
e. 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 MASTER 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:
15. Who maintains the business entity's fnancial and business records?
16. Where are these fnancial and business records kept? Address Line 1:
Address Line 2: City: State: Zip Code:
17. Who prepares the business entity's tax returns and governmental registrations and flings?
18. Has the business entity entered into a lease or agreement with a manufacturer or distributor for the licensing of software, hardware, or any
part of Class B machines? Yes No
19. List the names of all manufacturers, suppliers, and distributors of the COAM machines, parts, hardware and software?
20. Is this business a Georgia Lottery retailer? Yes No If Yes, enter 6 digit retailer number:
21. Business Information Prepared by:

Name Title Date

f. Name: % of Ownership:
g. Name: % of Ownership:
h. Name: % of Ownership:
i. Name: % of Ownership:
j. Name: % of Ownership: