Form Dol-129 - Retailer Application Page 3
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45. Are any of the individuals listed in the officer information section non-U. S. Citizens? ____ Yes ____No
If yes, list the individual’s name, mother’s maiden name, father’s name; passport number, permanent resident or I-94 number;
the last permanent address prior to entering the U.S. and the last date of entry into the U.S.
Individuals listed in Section 2 above who are non-U.S. citizens shall be required to complete a Lottery Personal Inquiry Waiver
Form DOL-102-D and a U.S. Department of Justice Certification of Identity form DOJ-361 pursuant to Rule 53ER12-67 to complete
international background investigations.
CERTIFICATION:
An attorney in fact may not make any affidavit as to the personal knowledge of the principal.
I HEREBY
CERTIFY that the information contained on this form or otherwise submitted to the Florida Lottery in connection with my
application to become a retailer is true and correct in every material respect. I understand that providing inaccurate or misleading
information is grounds for rejection of this application or cancellation of the Retailer Contract. The Florida Lottery is authorized to
obtain criminal background, Florida tax, credit, and general information about me, my business, and any persons listed on this
application, which may assist in making a decision on this application. The business location where lottery tickets will be sold is in
compliance with the accessibility requirements set forth in sections 553.501 - 553.513, Fla. Stat., the Florida Americans with
Disabilities Accessibility Implementation Act.
_________________________________________________________
State of _______________________________________
Signature of authorized corporate officer, partner, or owner
County of _____________________________ _______ __
_________________________________________________________
Sworn to or affirmed and subscribed before me this
Print or type name
__________________ day of ______________, ______,
(Day)
(Month)
(Year)
_________________________________________________________
Title
by ___________________________________________ _
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Signature of Notary Public
(Print, Type or Stamp Commissioned Name of Notary Public)
_____ Personally Known or _____ Produced Identification
Type of
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Affix Notary stamp above.
Certificates of Authority and retailer contracts are not assignable or transferable between persons or locations.
STATEMENT OF PUBLIC DISCLOSURE: Information contained in this application shall be open to the public for inspection.
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