Form Dol-129 - Retailer Application
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4RETAILER APPLICATION
FOR LOTTERY USE ONLY
Florida Lottery
ID#
CHAIN#
250 Marriott Drive
PROSPECT#
Tallahassee, FL 32399-6573
(850) 487-7714 or
DO
Non-refundable Application Fee: Payable to the Florida Lottery by check or money order.
Initial Application $100, Additional Location $25, Change of Location $10,
New Officer, Director or Shareholder $25 each.
A retailer applicant shall be required to post a bond, certificate of deposit or other security if it is determined during the background
investigation that such requirement is necessary to secure payment of lottery proceeds.
Check application type and complete the information below – PLEASE PRINT OR TYPE:
INITIAL APPLICATION
100% SALE OF STOCK
NEW OFFICER(S), DIRECTOR(S), SHAREHOLDER(S)
ADDITIONAL STORE LOCATION
CHANGE OF LOCATION: Date of Relocation ________________________________
CHANGE OF OWNERSHIP: Previous Location ID# ____________________________ Date of Sale ___________________
For information concerning sale of business: Contact Name _____________________ Phone Number ( _______ ) _______– __________
SECTION 1 - BUSINESS INFORMATION
1. CORPORATE OR OTHER LEGAL NAME: _____________________________________________________________________
2. STORE NAME (dba): ___________________________________________ 3. STORE PHONE: ( ______ ) ______ – _________
4. STORE ADDRESS: _______________________________________________________________________________________ __
Street
City
State
Zip Code
County
5. MAILING ADDRESS: _______________________________________________________________________________________
Street or P.O. Box
City
State
Zip Code
6. CONTACT NAME AND TITLE: _______________________________________________________________________________
First
Middle Initial
Last
Title
7. CONTACT NUMBERS AND E-MAIL ADDRESS:
( ______ ) ______ – ______________
( ______ ) ______ – ______________
( ______ ) ______ – ______________
Phone
Alternate Phone
Fax Number
_____________________________________________________________________ _
E-mail Address
8. TAXPAYER IDENTIFICATION NUMBER: Provide number used to file business income tax return.
Sole Proprietors, list Social Security Number. All other entities, list Federal Employer Identification Number.
____ ____ _____ _____ _____ _____ _____ _____ _____
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10. ALCOHOLIC BEVERAGE LICENSE NUMBER: ____ ____ -____ ____ ____ ____ ____
Applied For
Not Applicable
11. MINORITY BUSINESS:
YES
NO (If yes, check appropriate minority category)
__ African American
__ Native American
__ Hispanic American
__ American Woman
__ Asian American
12. BUSINESS TYPE: (Check One)
__ Corporation
__ Partnership
__ Non Profit
__ Sole Proprietorship
__ Limited Partnership
__ Limited Liability Company
__ Limited Liability Partnership
13. START DATE OF BUSINESS: __________________________________________
14. CORPORATE CHARTER OR DOCUMENT NUMBER: ____________________________________
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DOL-129 (Revised 8/13)
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