Ticket Lottery Licence Application
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1
2Organization RSN__________
Ticket
Property RSN
__________
Office use
only
Folder RSN
_____________
Lottery Licence Application
Entered
______________
Applicant
Applicant Information
1) Has your organization previously held
Organization Name: _________________________________________
a lottery?
Yes
No
If Yes, what was the last licence number?
___________________
_________________________________________________________
2) Is your organization a registered charity
Mailing Address: ___________________________________________
with the Charities Directorate?
Yes
No
If Yes, what is the registration number?
___________________
_________________________________________________________
City/Town: ________________________________________________
3) Is your organization incorporated as a
non-profit organization?
Yes
No
Province: ____________________ Postal Code: __________________
If Yes, what is the incorporation number?
___________________
Phone: _____________________ Fax: _________________________
4) Approximately how many members are in
your organization?
___________________
Proposed Use of Proceeds
Provide details as to how proceeds will be used: (Attach a separate sheet if necessary.)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Draw Location/ Ticket
Location of Draw(s): _________________________________________
Attach sample copy of ticket.
Address: __________________________________________________
Note: Draw details cannot be changed after ticket sales begin.
__________________________________________________________
The total value for the tickets sold for any one event shall not exceed
twelve times the total retain value of the prizes.
City/Town: ____________________ Province: ____________________
To be signed by two Principal Officers of the Organization
We certify that all information and documents supplied are correct and the organization has authorized us to make this application.
Name: ___________________________________________________
Name: ____________________________________________________
Position: _________________________________________________
Position: ___________________________________________________
Address: _________________________________________________
Address: ___________________________________________________
_________________________________________________________
__________________________________________________________
City/Town: ________________________________________________
City/Town: _________________________________________________
Province: _________________ Postal Code: ____________________
Province: __________________ Postal Code: ____________________
Phone (W): ________________ Phone (H): ______________________
Phone (W): _________________ Phone (H): ______________________
Signature: ________________________________________________
Signature: __________________________________________________
Date: ______________________
Date: ______________________
Application can be dropped off at any
Service Centre, 149 Smallwood Drive, Mount Pearl, NL A1N 1B5
Service Centre or Mailed to:
Fax: 1 (709) 466-4070 or 729-6998 Phone: (709) 729-2660 or 1-877-968-2600
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