Scel Retailer License Application - South Carolina Education Lottery Licensing Department Page 5
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8Fill out each
section.
SCEL Retailer License Application
Schedule A
– Page 2 -
Owner Information
Step 5:
These questions pertain to all persons listed in Sections 3 and 4.
YES
NO
If you answer “yes” to any of the following questions, provide an explanation on Schedule C.
Has any person listed in Section 3 or 4 been convicted of a criminal offense related to the security or integrity of
a.
the Lottery in this or another jurisdiction?
Has any person listed in Section 3 or 4 been convicted of unlawful gambling activity, false statements, false
b.
swearing, or perjury in this or another jurisdiction?
Has any person listed in Section 3 or 4 been convicted of a crime punishable by more than one year of
c.
imprisonment or a fine of more than one thousand dollars?
Has any person listed in Section 3 or 4 been found to have violated the provisions of the Lottery Act or a
d.
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regulation, policy or procedure of the South Carolina Education Lottery?
Is any person listed in Section 3 or 4 a supplier of goods and services to the lottery or an employee or agent of a
e.
supplier who does business with the South Carolina Education Lottery?
Is/Are the owner(s) under the age of twenty-one?
f.
If so, is the company business type a Sole Proprietorship? Yes or No ?
Has any person listed in Section 3 or 4 ever had a Lottery or gaming license revoked in any state?
g.
Has the entity or any person listed in Section 3 or 4 had a lottery license revoked/terminated in SC?
h.
Does any person listed in Section 3 hold a license under the South Carolina Deferred Presentment Services Act?
i.
If so, please provide the complete business address on Schedule C for each location.
Step 6:
Is the applicant company a Small and Minority firm?
If yes, please check one of the boxes below.
Y
N
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2
Black 3
Asian 4
Hispanic 5
East Indian 6
Native Amer. 7
Caucasian Female 8
Othe
r
To request information on Small and Minority Business certification, call 803-734-0657.
Step 7:
Is the legal entity or company / sole proprietor subject to backup withholding? Yes ____ No ___
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Note: If you are not sure, call the IRS for clarification regarding whether the company is subject to backup withholding.
This form will serve as a W-9 form for this applicant if the applicant is subject to backup withholding.
APPLICATION CONTACT
Step 8:
If SCEL has a question about your application, who should we contact for clarification?
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CONTACT NAME
PHONE NUMBER
FAX NUMBER
BUSINESS TITLE
APPLICANT (LEGAL ENTITY, COMPANY, SOLE PROPRIETOR) MUST BE CURRENT IN FILING ALL APPLICABLE S. C.
STATE TAX RETURNS AND MUST BE CURRENT IN THE PAYMENT OF ALL STATE TAXES (INCLUDING INTEREST AND
PENALTIES). THE DEPARTMENT OF REVENUE (DOR) IS RESPONSIBLE FOR REVIEWING TAX INFORMATION AND
VERIFYING THAT ALL FILINGS AND TAXES ARE CURRENT. A LOTTERY RETAIL SALES LICENSE WILL NOT BE
ISSUED UNTIL DOR CERTIFIES THAT THE APPLICANT IS CURRENT. THIS REQUIREMENT APPLIES TO THE LEGAL
ENTITY AND DOES NOT APPLY TO THE OPERATIONAL MANAGER OR EMPLOYEES.
I hereby certify that I am authorized to act on behalf of the applicant. I certify that the information provided to the South
Carolina Education Lottery (SCEL) is true and complete. I understand and agree that it is a violation of state law to make a
statement of material fact to the SCEL knowing that the statement is false. I agree to be bound by the terms and
conditions of my current retailer contract while this renewal application is pending. I authorize SCEL to investigate
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business and personal financial records, criminal history and any other matter pertaining to the authenticity of statements
made in this application process. I authorize the South Carolina Department of Revenue to release to the SCEL all
information relating to all tax returns filed with the State of South Carolina relating to the payment of all taxes, interest and
penalties owed to the State of South Carolina.
AUTHORIZED SIGNATURE
DATE
:
___ _________________________________________
If business is registered with the State as a Sole Proprietorship, owner must sign.
PRINTED NAME
TITLE
Rev. 010106 -- SC Education Lottery Application -- Page 2 of 5
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