Montana Form Lotapp 5003 - Lottery Application
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1
2MONTANA
LOTAPP
Rev. 7-06
Return to:
Montana Department of Revenue
Liquor Control Division
Lottery Application
P.O. Box 1712
Helena, MT 59604-1712
Section 1: Entity/Transaction
If individual, list individual’s name
Check appropriate boxes:
2. Transaction
If corporation, list corporate name and all stock holders owning
1. Business Entity
New City Beer
10% or more of the total stock
Individual
New “Floater” All-Beverage
If other:
Corporation
New Restaurant Beer/Wine
•
If more than one individual, list all individuals’ names
•
Other
New All-Beverage
If a partnership, list partnership name and all individual
partners’ names
3. City/County quota area:
•
If LLC or LLP, list LLC/LLP name and all members names
________________________
Section 2: General Information
1. Name of Applicant/Business Entity _____________________________________________________________
Address ___________________________________________________________________________________
City, State, Zip _____________________________________________________________________________
Contact Person ________________________________________ Daytime Contact Phone _________________
If applying for a Restaurant Beer/Wine License, answer the following:
Has your restaurant existed for one year prior to the lottery deadline and have you operated it continuously since
then?
Yes
No
If yes, what is the physical address of the premises ________________________________________________
If your business is seasonal, has your restaurant existed for one year prior to the lottery deadline and have you operated
it continously during your normal business season since then?
Yes
No
Have you been an unsuccessful entrant in a previous restaurant beer/wine lottery held by the Department of Revenue?
If yes, provide information requested.
Yes
No
Date of lottery _______________ City where applied _______________ Applicant name __________________
Is there currently a retail license for the sale of beer, wine, or any other alcoholic beverage issued to the above
described location?
Yes
No
(If “yes” to this question, you do not qualify for entry into the lottery)
Has there been a retail license for the sale of beer, wine or any other alcoholic beverages issued to the above
described location within the last 12 months?
Yes
No If yes, explain.
License type and/or number _____________________________________________
Explanation ________________________________________________________________________________
Check the seating capacity for your restaurant
60 persons or less
61 to 100 persons
101 persons or more
Only one (1) lottery application per person will be accepted. “Person” as defined in ARM 42.12.401 means any
individual, firm, partnership, limited liability company, corporation or association.
Section 3: Declaration and Affidavit
If my application is drawn in the lottery, I agree to return a completed license application, accompanying documents and
the appropriate fees within 30 days of being notified that I was the successful applicant drawn in the lottery. I further
understand that all responses concerning ownership on this application must match the license application or I will not be
considered.
__________________________________________________
__________________________
Signature
Date
__________________________________________________
__________________________
Printed Name
Title
Note: If the applicant is a corporation, LLC or LLP the statement on the back must be completed.
Important: You must return only this lottery application by the deadline set in the publication notice. If the application is
not complete it will be disqualified. For information or details concerning the deadline for the specific area you are applying
for, please contact the department at 444-6900. Each lottery entrant will be notified.
5003
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