Form Lotapp - Lottery Application Page 2
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1
2Ownership Information (includes Corporations, LLC’s, LLP’s and Partnerships)
The stockholders, members/partners are (please print):
Number
of Shares/
Social Security
Date of
Name
Address
Percentage
Number
Birth
of
Ownership
The officers and directors of the corporation are (please print):
Name
Address
Title
ALL APPLICANTS ARe RequIReD TO SIgN AND COMPLeTe THe SeCTION BeLOw:
I, _________________________________________________________ , declare under penalty of false swearing that the
Print Name
information on this corporate statement is true and complete.
Signature _________________________________________________________ Date ____________________________
Declaration and Affidavit
If my application is drawn in the lottery, I understand that I must submit a completed license application and the
appropriate fees within 30 days (60 days for a “floater”) of being notified that I was the successful applicant. I further
understand that information concerning ownership on this application must be consistent with the license application and
supporting documents or I will be disqualified. For example, if you complete this application as an “individual,” and are
the successful applicant, your subsequent license application must also be as an individual.
Important: You must return this lottery application by the deadline set in the publication notice. If the application is not
complete, it will be disqualified. For information concerning the deadline for the specific area where you are applying,
please call us at (406) 444-6900 or (866) 859-2254. Each lottery applicant will be notified of the drawing results.
Signature _________________________________________________________ Date ____________________________
Printed Name ________________________________________ Title _________________________________________
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Parent category: Financial