Renewal Application For Registration - Lottery Retail Contract Manager Or Designate Contract Manager
ADVERTISEMENT
1
2
3
4Print Form
Clear Form
Renewal Application for Registration
Lottery Retail Contract Manager or
Designate Contract Manager
Gaming Policy and Enforcement Branch – Registration and Certification Division
Mail: PO Box 9202, Stn Prov Govt, Victoria, BC V8W 9J1
Courier: 3rd Floor, 910 Government St., Victoria, BC V8W 1X3
Telephone: (250) 356-0663 | Website:
BEFORE YOU START
Use this application to renew your Lottery Retail Contract Manager registration or Designate Contract Manager registration with the
Gaming Policy and Enforcement Branch (GPEB) for a three year period. If you are not currently registered, please complete an initial
Application for Registration - Lottery Retail Contract Manager or Designate Contract Manager form, available at:
/registration
.
Complete this renewal application if you continue to have managerial responsibility for a lottery retail business, but your personal
registration is going to expire. An electronic version of the renewal form is also available at
/registration
.
Items in ‘Section 4 – Additional Requirements (Application Attachments Etc.)’ are required to complete this renewal application.
Incomplete renewal applications will not be processed. Your business will not be permitted to sell lottery products until the
contract manager or designate contract manager is fully registered with the Gaming Policy and Enforcement Branch.
During the application renewal process you are required to advise GPEB immediately of any changes to the information you have
submitted in your application. If it is determined after you have been registered that your answers on this application were not
complete or correct, your registration may be cancelled.
Submit original applications and all supporting documentation by mail or courier only; please do not fax (see addresses at the
beginning of this application form). Keep a copy of this renewal application and all submitted documents for your records.
SECTION 1 – APPLICANT INFORMATION
PLEASE PRINT CLEARLY
Surname: (current legal surname)
First name: (legal first name)
Middle name(s): (legal middle names or N/A)
Home address: (current address) Unit and Street
City
Province
Postal Code
Mailing address for correspondence: (if different than above) Unit and Street
City
Province
Postal Code
Home phone number: (XXX) XXX-XXXX
Business phone number: (XXX) XXX-XXXX
Cell phone number: (XXX) XXX-XXXX
ext
Date of birth: (YYYY-MM-DD)
E-mail address: (provide a valid e-mail address)
Are you a Canadian citizen:
Immigration status: (i.e. visitor, working visa, landed immigrant, etc.)
If NO, you must supply landed immigrant or
Yes
No
work permit documents, or permanent residence card.
Legal name of lottery retail business: (corporate name)
Lottery retail number:
SECTION 2 – DISCLOSURE A
Full disclosure of all incidents and offences is required, including Young Offender information pursuant to Section 119(1)(o) of the Youth
Criminal Justice Act. Failure to fully disclose all incidents and offences is deemed sufficient grounds to deny your application.
Since your last lottery retail
Arrested
Yes
No
registration application, in any
jurisdiction, have you been:
Stopped or Detained (such as for shoplifting, impaired driving or any other offence)
Yes
No
Charged with any criminal offence, whether found guilty or not
Yes
No
Diverted or received Alternate Justice (such as for theft, shoplifting)
Yes
No
Convicted of any criminal offence, regardless of the sentence
Yes
No
Investigated or had a claim made against you by anyone (based in whole or in part on fraud,
Yes
No
deceit, misrepresentation, breach of trust or similar conduct)
Keep your personal information safe. Your completed copy of this form
December 23, 2013
should be stored in a safe and secure place, or should be destroyed in a secure manner.
Page 1 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dtf-719 - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes Or Tobacco Products
Financial
Instructions For Form Dtf-719 - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes Or Tobacco Products
Financial
Form Dtf-719-mn - Renewal Application For Registration Of Retail Dealers And Vedning Machines For Sales Of Cigarettes And Tobacco Products
Financial
Form Dtf-719-mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products - New York State Department Of Taxation And Finance
Financial
Form Dtf-719-mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products
Financial
Form Dtf-719-mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products - Nys Dept.of Taxation
Financial
Dtf-719-mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products
Financial
Related Categories
Parent category: Life