Form Dol-129 - Retailer Application Page 4
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4MARKETING EVALUATION/SITE SURVEY
_____________________________
Store Name:
COMPLETE WITH LOTTERY SALES REPRESENTATIVE
1. TRADE STYLE
(Circle One)
Airport Location
Convenience Store-
Hardware/Building Supplies
Restaurant - No Liquor
Shopping Mall Location
Appliances
no gas pumps
Hotel/Motel
Small Grocery/Meat/Fish Market
Auto Parts
Convenience Store-
Ice Cream Shop
Jewelry Store
Sports Arena/Amusement Park
Bakery
with gas pumps
Laundry/Dry Cleaner
State Agency
Bar/Tavern/Lounge
Department Store
Mail Services/Copy Center
Supermarket
Barber Shop/Hairdresser
Dollar Store/Discount Store
Municipality/Political Subdivision
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Beauty Shop
Drug Store/Pharmacy
Newsstand/Tobacconist/Sundries
Travel Agency
Bingo Hall
Financial Services
Flea Market
Non-Profit Organization
Travel Plaza/Truck Stop
Bowling Alley
Car Wash
Florist
Package Liquor Store
Video Store
Clothing/Shoes
Gas Station/Auto Repair
Pari-Mutuel
Wholesale Club
Coffee/Deli/Sub Shop
Gift/Card Shop
Restaurant - Liquor
Other ______________________ _
2. BUSINESS OPERATION:
SEASONAL BUSINESS
YEAR-ROUND BUSINESS
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Business Hours
FROM …………
TO ……………..
3. RETAILER INSTALLATION INFORMATION:
New Construction or Store Not Open? Please Check.
Yes
No
If yes, complete a, b, & c below.
a. Store opening date: __________________________
b. Approximate date for terminal and communications equipment installation:
__________________________
c. Building contact name and phone number
: _________________________________________________________
Retailer Owns Location? Please Check.
Yes
No
If no, complete a & b below.
Retailers with a lease agreement must have their landlord’s approval for the installation of
communications equipment on the roof and the installation of cables inside the location.
a. Landlord contact name:
________________________________________________________________________________________
b. Landlord phone number
:________________________________________________________________________________________
4. COMMENTS:
Sales Representative: __________________________________________________________________________________ _____________
_____________________________________________________________________________________________________ ______________
________________________________________________
___________________
___________________
______________________
Lottery Sales Representative Signature
SR#
Stop#
Date
Lottery District Manager: ___________________________________________________________________________________________
____________________________________________________________________________________________________ _______________
___________________________________________________________________________________________________ ________________
________________________________________________
______________________
Lottery District Manager Signature
Date
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