Form Dol-129 - Retailer Application Page 2
ADVERTISEMENT
1
2
3
4SECTION 2 - OFFICER INFORMATION
THE LOTTERY SHALL NOT CONTRACT WITH ANY PERSON WHO IS RELATED TO AND RESIDING WITH
ANY EMPLOYEE OF THE LOTTERY.
Are any of the individuals listed below related to an employee of the Florida Lottery in one of the following ways: husband,
wife, parent, grandparent, spouse’s parent, child, brother, sister, spouse of a child, aunt, uncle, grandchild, niece, nephew,
first cousin, and living in the same household as the employee? ____ Yes ____No
LIST ALL OWNERS, INDIVIDUAL PARTNERS, MANAGING MEMBERS, CORPORATE OFFICERS, DIRECTORS. LIST SHARE -
HOLDERS OF 10% OR MORE OR LIMITED PARTNERS WITH 10% OR MORE INTEREST IN THE BUSINESS. IF MORE SPACE IS
REQUIRED, PLEASE ATTACH ADDITIONAL SHEETS .
Birthdate (MM-DD-YY)
Name
Phone
Title
(first, middle initial, last)
Home Address
City
State
Zip
Social Security Number
Sex
Race
% Ownership
Birthdate (MM-DD-YY)
Name
Phone
Title
(first, middle initial, last)
Home Address
City
State
Zip
Social Security Number
Sex
Race
% Ownership
Name
Phone
Birthdate (MM-DD-YY)
Title
(first, middle initial, last)
Home Address
City
State
Zip
Social Security Number
Sex
Race
% Ownership
Birthdate (MM-DD-YY)
Name
Phone
Title
(first, middle initial, last)
Home Address
City
State
Zip
Social Security Number
Sex
Race
% Ownership
Birthdate (MM-DD-YY)
Name
Phone
Title
(first, middle initial, last)
Home Address
City
State
Zip
Social Security Number
Sex
Race
% Ownership
Have any of the individuals listed above:
1. Been convicted of, or pleaded guilty or nolo contendere to a felony within the last 10 years,
regardless of adjudication?
____ Yes ____No
2. Been convicted of, or pleaded guilty or nolo contendere to any gambling offense within the last
____ Yes ____No
10 years, regardless of adjudication?
3. Been arrested and have any pending criminal charges that have not been resolved?
____ Yes ____No
4. Been a Florida Lottery Retailer?
____ Yes ____No
If yes to questions 1, 2, 3 or 4, please explain response and include dates below (use additional sheet if necessary).
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal