13.

Place of Birth: City:

State: Country:
14. Height: 15. Weight: 16. Hair Color: 17. Eye Color:
18. Do you reside in the same household as any offcer or employee of the Georgia Lottery Corporation? Yes No
19. Are you a vendor, employee or agent of any vendor of the Georgia Lottery Corporation? Yes No
20. Have you been convicted of a criminal offense related to the security or integrity of the lottery in this or any
other jurisdiction? Yes No
21. 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 fne
of more than $1,000.00 or both? Yes No
22. Are you delinquent in taxes, fees or other obligations owed to the State of Georgia? Yes No
23. Have you fled bankruptcy in the last seven (7) years? Yes No
24. Are you related to a COAM Class B License holder? Yes No
Note: If you answered Yes to any of the above questions, please explain on a separate sheet and attach to this application.
25. Personal Information Prepared by:


Name Title Date
Signature Print Name Date
STATE OF: COUNTY OF:
SWORN TO AND SUBSCRIBED BEFORE ME ON THIS DAY OF (MONTH) (YEAR)
Notary Public Seal and Signature: My Commission Expires:
Personal Identifcation (ID) is required to be presented to and verifed by Notary Public. Type of ID: ID Number:
Revised May 2014
CLASS B LOCATION LICENSE ID#:
PART 2 - Personal Information
Coin Operated Amusement Machine Application
GEORGIA LOTTERY CORPORATION P.O. Box 56927 Atlanta, GA 30343
1-800-746-8546 - OPTION #4 - Retailer Contracts Administration
This information must be completed for each of the primary
(top 10) owners, partners, and shareholders of the business.
1. First, Middle & Last Name of Owner or Principal: 2. M or F: 3. Title: 4. Race: 5. Date of Birth:
6. % of Ownership: 7. E-mail: 8. Primary Phone Number: 9. Alternate Phone Number: 10. Social Security Number:
11. Home Address:
Address line 1:
Address line 2:
City: State: Zip Code:
a.
b.
c.
d.
12. List all other names you have used, including nicknames, surnames
other than your true name, or if female, furnish your maiden name:
First Middle Last
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
Applicants application to become a Bona Fide Coin Operated Amusement Machine (COAM) licensee is true and correct in every respect. Specifcally, I certify that
I have reviewed both the Applicants Business Information Page(s) as submitted, and my own Owner Information Pages for this application, and I certify that the
information contained therein 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 qualifcation of the Applicant as a COAM Licensee, which investigations may include, without limitation, criminal history
record information, credit history records, tax records, public records and other offcial records, and the investigation generally of any other matter relating to both
me and the Applicant being a COAM Licensee. As a potential COAM Licensee or a current COAM Licensee, licensed by the GLC, or as an owner of same, I am
required to furnish certain information for use in determining my qualifcations. 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 COAM Licensee Application. I authorize GLC to share any such information,
privileged, confdential or otherwise, necessary to consider the application to become a COAM Licensee. I further consent to allow GLC to use and share such
information in any and all manners consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out
of the relationship between the 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 fnal termination of the Applicants COAM License obligations to the GLC. I further understand and
acknowledge that providing inaccurate or misleading information is grounds for rejection of this application and suspension or cancellation of the COAM License
and may subject the Applicant and me to the penalties set forth in the Georgia Lottery for Education Act, O.C.G.A. 50-27-1, et seq.