Breakopen Lottery Licence Application
ADVERTISEMENT
1
2Organization RSN__________
Breakopen
Office use
Property RSN
__________
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.)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Breakopen Event(s) Location
Name of the premises: _________________________________
The premises is owned by: ___________________________________
____________________________________________________
________________________________________________________
Street Address: _______________________________________
____________________________________________________
Rent: $ _____________ per _____________
City/Town: ___________________________________________
Is the premises a licenced liquor outlet?
Yes
No
Province: ____________________________________________
If Yes, what category of liquor licence? ____________________
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
149 Smallwood Drive , P.O. Box 8700, St. John’s, NL, A1B 4J6
Service Centre or Mailed to:
Fax: 1 (709) 466-4070 or 729-6998 Phone: (709) 729-2660 or 1-877-968-2600
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business