Renewal Application For Registration - Lottery Retail Contract Manager Or Designate Contract Manager Page 2
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1
2
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4Renewal Registration
Gaming Policy and Enforcement Branch
Lottery Retail Contract Manager or Designate Contract Manager
SECTION 2 – CONTINUED
Cases: (complete this section if you answered YES to any of the items in the first part of Section 2 – provide details as indicated below – list all cases
without exception including those in which you were not charged or convicted – attach a separate sheet if more space is required)
Date of Arrest / Detention:
Location:
(YYYY-MM-DD)
Age:
Charge / Claim:
(City, Prov / State)
Disposition:
Arresting Agency:
SECTION 3 – DISCLOSURE B
1. Have you been a defendant in any civil action related to fraud, theft, deceit, misrepresentation or similar conduct?
Yes
No
2. Have you been suspended, disqualified, censured or had disciplinary action instituted against you, as a member of a
Yes
No
profession or organization?
3. Have you had any license or permit issued to you or your place of business for which you received a warning, suspension,
Yes
No
revocation, conditions attached, or received any fine or penalty?
4. Have you declared bankruptcy or received assistance from a regulatory body or a court because of an outstanding debt?
Yes
No
If you answered YES to any of questions 1-4 above, provide details below: (attach a separate sheet if more space is required)
SECTION 4 – ADDITIONAL REQUIREMENTS (APPLICATION ATT ACHMENTS ETC.)
The following are required to complete this application: (submit all supporting documentation with your application)
Immigration papers or
If you are not a Canadian citizen, include a copy of your landed immigration papers or work permit, or
work permit
permanent residence card.
Signature
Your signature is required in Section 5 of this renewal application.
GAMING POLICY AND ENFORCEMENT BRANCH USE ONLY
CPIC
PSP
Interpol
PIRS
GOS
JUSTIN
Other _____________________
Checks conducted by:
Date:
Date of approval:
Approved by:
Approved
Rejected
GAMW #:
Application #:
Reg #:
Receipt #:
BE #:
Keep your personal information safe. Your completed electronic or paper copy of this form
December 23, 2013
should be stored in a safe and secure place, or destroyed in a secure manner.
Page 2 of 4
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