Lottery Licensing Eligibility Form

Name of organization:

Municipal address:

City/Town:

Province:

Postal code:

Email address:

Type of Lottery for which this application is being made (check one):

Bingo

Break-open / Nevada

Raffle / 50-50

Bazaar

Is the applicant incorporated as a non-profit organization in the Province of Ontario?

Yes

Is the APPLICANT registered with Canada Customs and Revenue Agency as a charitable organization?

Yes

Jurisdiction of incorporation:

How long has the organization been in existence?

How many persons comprise your bona fide membership?

Describe the requirements that a person must meet in order to become a bona fide member of your organization:

Describe your organization’s aims and objectives:

Indicate the specific purpose(s) to which the lottery proceeds will be applicable.

The Applicant Organization Lottery Trust Account (if open at this time)
NOTE: It will be required at the time of application.

Name of financial institution:

Address of financial institution:

City/Town:

Province

Postal Code:

Account number:

Applicant's fiscal year-end date:

The designated member of the organization who will be responsible for keeping and maintaining records of all financial transactions pertaining to the licensed lottery activities:

Name:

Business address:

City/Town:

Province:

Postal code:

Telephone number (business):

Email address:

Names of bona fide members who will conduct one or more of the lottery events referred to on this application:

Name	Name
Name: 1.	Name: 6.
Name: 2.	Name: 7.
Name: 3.	Name: 8.
Name: 4.	Name: 9.
Name: 5.	Name: 10.

We, the undersigned, declare that all information provided in and with this statement is factual and correct.

Name of Principal Officer:

Title:

Date:

Name of Principal Officer:

Title:

Date:

I have read the Mandatory Documents Requirement, and agree to submit the required documents set forth in the checklist.

Alerts

Lottery Licensing Eligibility Form