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Blank Ga Lottery Application PDF Template

The Georgia Lottery Application form is a comprehensive document designed for entities applying to become Georgia Lottery Retailers. This form encompasses various segments including business information, personal information of owners or principals, electronic funds transfer authorization, and a retailer contract. Costing $125 per business location, with a portion refundable under certain circumstances, it requires detailed information to ensure compliance and eligibility for participating in the Georgia Lottery operations. Interested parties are encouraged to meticulously fill out the form and click the button below to proceed with their application.

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Blank Ga Lottery Application PDF Template

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Navigating the Georgia Lottery Corporation Retailer Application process is pivotal for businesses aiming to sell lottery tickets. This comprehensive procedure involves a detailed application packet that guides prospective retailers through several essential steps, starting with a business information segment that requires a financial commitment of $125 per location. This initial investment is partially refundable if the application does not meet approval. Applicants must provide thorough details about the business entity, including the legal name, operational name, addresses, contact information, and the principals involved, all of which play a critical role in the Georgia Lottery Corporation's assessment process. Moreover, the application delves into personal information for each business owner or principal, emphasizing the necessity for transparency through the disclosure of personal identification, background checks, and potential criminal history. Additionally, the form introduces an Electronic Funds Transfer Authorization section, crucial for the financial transactions involved in lottery sales. This part mandates the establishment of a dedicated trust account for managing lottery proceeds. The final component of the application—Retailer Contract—outlines the operational, financial, and legal obligations of lottery ticket sales, including compliance with regulations, prize payments, promoting sales, and managing instant ticket returns. Overall, the application form serves as a gateway for businesses to partake in the Georgia lottery system, embodying a complex blend of legal, financial, and operational considerations.

Preview - Ga Lottery Application Form

GEORGIA LOTTERY CORPORATION

Instructions for Retailer Application Packet 1-800-746-8546 - OPTION #4 & then #7 - Retailer Contracts Administration

Revised 4/1/18


	PART 1 - Business Information
	PART 1 - Business Information		PART 2 - Personal Information (Owner)

A Georgia Lottery Retailer application must be accompanied by a Cashier’s Check, Business Check or Money Order for $125 per business location. (In the event the application for a business location is not approved by the Georgia Lottery Corporation, $100 of the $125 will be refunded.)

This form must be completed for each owner, shareholder, member, and officer of the business. Make additional copies if necessary.

Lines 1 - 14 - List all information requested.

Line 1 - List the name of the entity which owns the business and files Income tax returns.

Line 2 - List the name of the business where tickets are to be sold.

Line 3 - 8 - List the business address, business telephone #, city, state, zip, & county

Lines 9 - 12 - List the mailing address, if different from #3 above: otherwise, please leave this blank.

Line 13 - List fax number, if applicable.

Line 14 - List each Principal of the Business. Please attach additional sheets as needed. EACH LISTED INDIVIDUAL MUST ALSO COMPLETE PART 2 OF THIS APPLICATION.

Line 15 - Complete, sign and have this statement notarized.

Line 16 - Business Contacts – Name, title, and phone number of the person(s) the Lottery should contact on all Lottery business.

Line 17 - COAM information - Complete all information requested for Coin Operated Amusement Machines.

Line 18 - Optional - If the majority ownership (more than 50%) of the business is held by a person or persons of a minority race, it is requested, but not mandatory, that this section be completed. Minority Business Ownership is defined in Georgia statutes as follows:

•For a proprietorship: A business owned by “an individual who is a member of a minority who reports as his personal income for

Georgia Income tax purposes the income of such business”; or

•For a partnership: “A partnership in which a majority of the ownership interest is owned by one or more members of a minority who report as their personal income for Georgia income tax purposes more than 50 percent of the income of the partnership”; or

•For a corporation: “A corporation organized under the laws of this state in which a majority of the common stock is owned by one or more members of a minority who report as their personal income for Georgia Income tax purposes more than 50 percent of the distributed earnings of the corporation.”

Line 19 - Business Hours - List business hours for Sunday through Saturday.

LOTTERY OFFICIAL TO COMPLETE ALL SHADED ENTRIES

Line 15 - If answering “yes” to any of these questions, please explain on a separate sheet and attach to this application.

Lines 16 - 21 - List all information requested.

Line 22 - Attach a copy of one of the following forms of identification (Driver's License, Georgia Identification Card, Identification Card issued by another state, U.S. Armed Forces Identification Card, U.S. Passport or U.S. Resident Alien Card).

Line 23 - Complete, sign and have this statement notarized.

PART 3 - Electronic Funds Transfer Authorization

Line 1 - List the name of the entity which owns the business and files Income tax returns.

Lines 2 - 4 - Obtain and list required licensing numbers from the Georgia Department of Revenue (State Tax Identifier, Sales Tax, & Alcohol).

Line 5 - The Federal Employers ID Number (FEIN) must be listed for partnerships and corporations. Sole proprietors must list the social security number only.

Line 6 - List all information requested and sign the authorization.

Line 7 - Must be completed and signed by Depository Institution Representative.

This verifies the establishment of an account “In Trust for the Georgia Lottery Corporation.” Attached is a letter to provide to your Bank Representative which provides an example of the account title requirements.

PART 4 - E-Verify Affidavit

The completed/executed affidavit is required of ALL GLC Retailer

Applicants. See the E-Verify Affidavit Instructions Letter for

important information regarding the completion of this affidavit.

PART 5 - Retailer Contract

A Contract must also be completed by each member of an LLC or Partnership. Make additional copies if necessary. Complete and sign page 2 of the Retailer Contract.

Business Trade Styles

Restaurant/Truck Stop

Auto Supply	Convenience	Home Improvement	Not Classified	Restaurants (Non-Fast Food)
Bar/Lounge/ Tavern	Convenience/Gas	Hotels & Other Lodging	Other Non-retail	Service/Gas Station
Bowling Center	Discount Department Stores	Independent/Grocery Store	Other Retail	Stationery/Gift/Newsstand
Check Cashing	Drug Store/Pharmacy	Major Supermarket Stores	Package Store	Value Stores
Coffee Houses	Fraternal Organizations	Mall Kiosk	Restaurant	Video Store

Retailer Application

GEORGIA LOTTERY CORPORATION

P.O. Box 56486 • Atlanta, GA 30343 1-800-746-8546 - OPTION #4 & then #7 - Retailer Contracts Administration

Please submit completed application with $125 fee per business location

(Cashier’s Check, Business Check, or Money Order only).

1 of 4

Revised 4/1/18

PART 1 - Business Information

PLEASE PRINT

Lottery Retailer ID#:

1.Corporate or legal name (List the name of the legal entity which owns the business and files income tax returns):

2.Store Name or d/b/a (list the name of the business where tickets are to be sold):

3.	Business Location:	(Street Number and Name of the location where lottery tickets are to be sold)		4. Business Telephone Number:
5.	City:	6. State:	7. Zip Code:	8. County:

9. Mailing Address (if different) (P.O. Box Number or Street Number and Name) :

10. City:

11. State:

12. Zip Code:

13. Fax Number:

14.List each owner, shareholder, member and officer of the Business (for example, sole proprietors, general partners, corporate officers, directors and shareholders). EACH LISTED INDIVIDUAL MUST COMPLETE PART 2 OF THIS FORM. Please attach additional sheets as needed:

a.	Name:	Percent of Ownership:
b.	Name:	Percent of Ownership:
c.	Name:	Percent of Ownership:
d.	Name:	Percent of Ownership:

15.Applicant certifies that the information contained on this form or otherwise submitted to the Georgia Lottery Corporation (“GLC”) in connection with this application to become a Retailer is true and correct in every respect. The undersigned certifies that he is duly authorized to act on behalf of the Retailer Applicant. Applicant understands, agrees, and consents that the GLC may make any and all investigations necessary in order to satisfy the GLC requirements for qualification of the Applicant as a GLC Retailer. Applicant hereby authorizes GLC to request criminal history record information, a credit report, or conduct any other investigation as may be necessary to process Applicant’s request to become a GLC Retailer.

Applicant authorizes GLC to share any such information, privileged, confidential or otherwise, necessary to consider its application to become a GLC

Retailer. Applicant further consents to allow GLC to use and share such information in all manner consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the relationship between Applicant and GLC. Applicant understands that providing inaccurate or misleading information is grounds for rejection of this application or cancellation of the Retailer Contract, and may subject the Applicant to the penalties set forth in O.C.G.A. §50-27-28.

Signature of Owner or Principal

Print or Type Name

Title

Date

NOTARY

STATE OF:

COUNTY OF:

SEAL

SWORN TO AND SUBSCRIBED BEFORE ME ON THIS

DAY OF

(MONTH)

(YEAR)

Notary Public Seal and Signature:

My Commission Expires:

HERE

Personal Identification (ID) is required to be presented to and verified by Notary Public. Type of ID:

ID Number:

16. Business Contacts (Persons Authorized to Conduct On-Site Lottery Transactions):

Name

Title/Function

Cell Phone #

17. Is this business location licensed for Coin Operated Amusement Machines (COAM)? ___Yes

___No

If Yes, provide the following:

# of Class A Machines:_________

# of Class B Machines:_________

COAM Location License #_________________________

COAM Master License # __________________________

18. (OPTIONAL) Is Business Ownership more than 50% of a minority race?

 Yes

 No

If yes, Specify:  African American

 Native American

 Asian

 Hispanic 

Other (specify):

19. Business Hours:

 Sunday

 Monday

 Tuesday

 Wednesday

 Thursday

 Friday

 Saturday

Open

To be completed by Lottery Representative

Business Trade Style: (see Instruction Sheet)

Retailer Application

2 of 4

GEORGIA LOTTERY CORPORATION

Make additional

P.O. Box 56486 • Atlanta, GA 30343

copies if necessary.

1-800-746-8546 - OPTION

#4 & then #7 - Retailer Contracts Administration

This form must be completed for each owner, shareholder, member, and officer of the business.

Revised 4/1/18

PART 2 - Personal Information (Owner)

PLEASE PRINT

Lottery Retailer ID#:

1. Type of Ownership:

 Sole Proprietor  Partnership

Corporation

 Non-Profit

 LLC (Corporation)  LLC (Partnership)

 Other(specify):

First, Middle & Last Name of Owner or Principal (no initials):

M or F:

4. Place of Birth:

Title:

Race:

7. Percent of Ownership:

8. Date of Birth:

Home Street Address:

10. City/State/Zip Code:

11.

Home Phone Number:

12. Cell Phone Number:

13.

Social Security

Number:

14. E-mail Address:

(

)

(

)

15.

•Do you reside in the same

household as any officer or

employee of the Georgia Lottery Corporation?

 Yes

 No

•Are you a vendor, employee or agent of any vendor of the Georgia Lottery Corporation?

 Yes

 No

•Have you been convicted of a criminal offense related to the security or integrity of the lottery in this or any other jurisdiction? If yes,

where? and when?

 Yes

 No

•Have you been convicted of any illegal gambling activity, false statements, false swearing or perjury in this or any other jurisdiction or

convicted of any crime punishable by more than one year of imprisonment or a fine of more than $1,000.00 or both ? If yes, where?

and when?	 Yes	 No
•Are you delinquent in taxes, fees or other obligations owed to the State of Georgia?	 Yes	 No
•Have you filed bankruptcy in the last seven (7) years?	 Yes	 No
•Are you related to a COAM Class B Master Licensee?	 Yes	 No

Note: If you answered “Yes” to any of the above questions, please explain on a separate sheet and attach to this application.

16.List all other names you have used, including nicknames; if female, furnish 17. Citizenship

maiden names. If you have ever used any surnames other than your true name,

a. Present citizenship (Country):

during what period and what circumstances were these used? If you have ever legally

b. Citizenship acquired by:

 Birth  Marriage  Naturalization

changed your name, give date, place, and court. (Attach additional page as needed):

c. Naturalization Certificate Number:

d. Date and place Naturalized:

e. Resident Alien Number:

18.

Height:

19. Weight:

20.

Hair Color:

21. Eye Color:

22.Attach a copy of one of the following forms of identification for each owner. The following is a list of acceptable forms of identification: Driver's License, Georgia Identification Card, Identification Card issued by another state, U.S. Armed Forces Identification Card, U.S. Passport, or U.S. Resident Alien Card.

23.CONSENT AND AUTHORIZATION FOR RELEASE OF PERSONAL BACKGROUND INFORMATION:

I hereby certify that the information contained on this form or otherwise submitted by me to the Georgia Lottery Corporation (“GLC”) in connection with this application to become a GLC Retailer is true and correct in every respect. I understand, agree and consent that GLC may make any and all investigations of my background in order to satisfy the GLC requirements for qualification of the Applicant as a GLC Retailer, which investigations may include, without limitation, criminal history record information, credit history records, tax records, public records and other official records, and the investigation generally of any other matter relating to the Applicant being a GLC Retailer. As a potential Retailer or current Retailer for the Georgia Lottery Corporation (“GLC”), or as an owner of same, I am required to furnish certain information for use in determining my qualifications. I hereby authorize GLC to request a credit report, conduct a criminal background investigation, or conduct any other investigation as may be necessary to process my Retailer Application to become a GLC Retailer. I authorize GLC to share any such information, privileged, confidential or otherwise, necessary to consider the application to become a GLC Retailer. I further consent to allow GLC to use and share such information in all manner consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising out of the relationship between the Retailer Applicant and GLC. A photocopy of this release will be valid as an original thereof, even though said photocopy does not contain an original writing of my signature. This release will expire upon the final termination of my Retailer’s contractual obligations with the GLC.


Signature			Print Name		Date

The foregoing authorization notwithstanding, for the limited purposes of initially qualifying a Georgia Lottery Retailer, the GLC will not order, as a routine business practice, credit reports or criminal record history reports for individuals owning 10% or less of the equity ownership interests in the Georgia Lottery Retailer applicant. The GLC does reserve the right in its sole discretion to order such reports in accordance with business exigencies.

NOTARY

SEAL

HERE

STATE OF:

COUNTY OF:

SWORN TO AND SUBSCRIBED BEFORE ME ON THIS

DAY OF

(MONTH)

(YEAR)

Notary Public Seal and Signature:

My Commission Expires:

Personal Identification (ID) is required to be presented to and verified by Notary Public. Type of ID:

ID Number:

Retailer Application		3 of 4
GEORGIA LOTTERY CORPORATION		3 of 4
P.O. Box 56486 • Atlanta, GA 30343
1-800-746-8546 - OPTION #4 then #7 - Retailer Contracts Administration		Revised 4/1/18

PART 3 - Lottery Retailer Electronic Funds Transfer Authorization	Lottery Retailer ID#:

1. Corporate or Legal Name (list the name of the legal entity which owns the business and files income tax returns):

2. Georgia State Tax Identifier Number (11

3. Georgia Alcohol License Number (if any, 7 digits):

4. Georgia Sales Tax Number (9

Service Business

Only

5.Federal Employers ID Number. 9 digit number used to file Federal business income tax return. (For Sole Proprietor use Social Security Number)

INSTRUCTIONS: The Retailer must establish a separate electronic funds transfer (EFT) bank account for the preservation and transfer of

lottery funds. The separate bank account must be specified “IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.” The Retailer’s depository institution must confirm the establishment of the Georgia Lottery Corporation Trust Account by signing in the space below.

6.RETAILER AUTHORIZATION: I (we) hereby authorize the Georgia Lottery Corporation to initiate debit and credit entries in any available and appropriate amount to my (our) account indicated below and authorize the depository named below to debit or credit the same to such account. I (we) hereby further authorize and direct the depository institution named below to release any information regarding such account, including, but not limited to, account balance information, payment history, and overdraft information to the Georgia Lottery Corporation upon request by an authorized representative of the Georgia Lottery Corporation. My (our) authorization is given in accordance with subsection

(e)(2) of Section 502 of the “Gramm-Leach-Bliley Act of 1999” (15 U.S.C.A. § 6802) and shall remain in effect until expressly revoked by me

(us) in writing. Any such revocation shall be deemed to have been properly given if sent by hand delivery, or by overnight courier, to such depository institution at the address set forth below. Such revocation shall be deemed to have been delivered on the date of delivery if by hand delivery or if by overnight courier, on the next business day following the deposit of such communication with the overnight courier.

Bank Account Name:

/“IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.”

Corporate or legal name of entity which owns the business and files income tax returns: (see attached example)

Bank Name (print):

Branch:

Bank Street Address:

City:

State:

EFT Bank Route Transit Number:

EFT Bank Account Number:

Signature of Owner or Principal:

Date:

Printed Name of Owner or Principal:

THE SECTION BELOW MUST BE COMPLETED BY DEPOSITORY INSTITUTION (BANK)

7.DEPOSITORY INSTITUTION ACKNOWLEDGMENT: The above account has been established “IN TRUST FOR THE GEORGIA LOTTERY CORPORATION.” We acknowledge that our customer, the Retailer, has directed us to provide information concerning the above referenced account to the Georgia Lottery Corporation upon request by an authorized representative of the Georgia Lottery Corporation. We further acknowledge that the Retailer has directed us to provide this information in accordance with subsection (e)(2) of Section 502 of the “Gramm- Leach-Bliley Act of 1999” (15 U.S.C.A. § 6802), and we will continue to provide such information as directed until receipt of Retailer’s written revocation in the manner set forth in Section 6 above.

Depository Institution Representative (print):	Telephone Number:
Signature of Depository Institution Representative:		Date:

		Retailer Application	4 of 4
	GEORGIA LOTTERY CORPORATION		4 of 4
	GEORGIA LOTTERY CORPORATION
	P.O. Box 56486 • Atlanta, GA 30343
1-800-746-8546 - OPTION #4 then #7 - Retailer Contracts Administration			Revised 4/1/18

Part 4 – Lottery Retailer E-Verify Affidavit		Lottery Retailer ID#:

The GLC Retailer, signed below, confirms and verifies its compliance with Georgia law (See OCGA §13-10-91, as amended), and affirmatively states that the business (Sole Proprietor, Partnership, Corporation, Non-Profit, LLC Corporation, or LLC Partnership) which sells GLC lottery tickets: (check and complete #1 or #2 below)

Legal Business Name of Georgia Lottery Retailer/Applicant:

____1. Has registered with, is authorized to use, and uses the federal work authorization program commonly

known as E-Verify, or any subsequent replacement program. Furthermore, the undersigned retailer will continue to use the federal work authorization program throughout the contract period. Retailer hereby attests that its federal work authorization user identification number and date of authorization are as follows:

_______________________________________________

Federal Work Authorization User Identification Number

This number is at least 4 or more digits in length, does not contain letters and is NOT your Federal Employer Identification Number (FEIN).

_______________________________________________

Date of Authorization

____2. Employs no employees, or otherwise does not fall within the requirements of OCGA §13-10-91.

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on _______________ DAY OF __________, 20 in _________________(city) _____________(state).

_________________________________________________________

Signature of Authorized Owner/Officer

____________________________________________________

Printed Name and Title of Authorized Owner/Officer

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF __________, 20___.

____________________________________________________________

NOTARY PUBLIC

My Commission Expires: ______________________________________

Important E-Verify Affidavit Instructions

Revised 4/1/18

Dear Valued GLC Lottery Retailer Applicant:

The Georgia Security and Immigration Compliance Act (OCGA §13-10-91) has been amended by the passage of Georgia Senate Bill 160, which implemented new retailer contract requirements for the Georgia Lottery Corporation (“GLC”).

As a result, all new GLC Retailers contracted after July 1, 2013 must submit an E-Verify affidavit to the GLC with their GLC Retailer application. The E-Verify affidavit provides proof of the retailer’s registration and participation in E-Verify, the current federal work authorization program.

Under the amended law, a new GLC retailer must submit an E-Verify affidavit with an E-Verify user number (Federal Work Authorization User Identification Number), unless the business has no employees (in which case it must present an approved state-issued identification card or driver's license, with an E-Verify affidavit that it has no employees).

The E-Verify Affidavit is attached:

a)Complete Section 1 of this affidavit to provide the GLC an E-Verify user number. If you are not currently registered in the E-Verify program and do not have an E-Verify number, one can be obtained on-line, for free, at http://www.dhs.gov/e-verify. For further information, visit the website or contact the U. S. Department of Homeland Security at 888-464-4218.

b)Your E-Verify number is at least 4 or more digits in length, does not contain letters and is NOT your

Federal Employer Identification Number (FEIN).

c)If your business has NO employees, place a check mark in section 2 and ensure a copy of an approved state-issued identification card or driver's license is provided with E-Verify affidavit.

d)Once an E-Verify user number is obtained for Section 1 or a copy of the state-issued identification card or driver’s license is obtained for Section 2, the business owner (or authorized representative of the business) on the original GLC contract must sign the affidavit, before a notary.

e)The notarized affidavit must be returned to the GLC with your completed GLC Retailer Application package.

If you have any questions, please contact your GLC Sales Representative, or the RCA (Retailer Contracts Administration) department at 1-800-746-8546 - option #4 then #7.

PART 5 - Retailer Contract

Lottery Retailer ID:

Revised 4/1/18

THIS RETAILER CONTRACT is between GEORGIA LOTTERY CORPORATION (GLC), a public corporation created pursuant to the Georgia Lottery for Education Act (Act), and the undersigned Retailer. Capitalized terms used herein shall have the meanings set forth in Appendix A to GLC's Retailer Rules and Regulations, unless otherwise defined in context. Subject to approval by GLC of Retailer’s application to sell lottery Tickets, Retailer and GLC hereby agree as follows:

1.Retailer Rules. Retailer agrees to comply with and be bound by the Act, the Rules and Regulations of GLC, and all other applicable laws, rules, regulations, ordinances and orders. Retailer agrees at all times to meet the minimum qualifications for a GLC Retailer and to notify GLC of any changes in its business, as specified in the Act and the Rules and Regulations. Copies of the Act and all

Rules and Regulations are always available upon request from GLC.

2.Term and Renewal, Unless earlier terminated, the term of this Retailer Contract shall begin as of the date it is executed by Retailer, as shown below, shall remain in effect for a period of one (1) year, and may be renewable annually at the sole discretion of

GLC. In the event that GLC and Retailer have entered into any Retailer Contract(s) dated prior to the date of this Retailer Contract, GLC and Retailer agree that from the beginning of the term hereof, this Retailer Contract shall amend, renew, replace, and restate any prior Retailer Contract in its entirety for each Retailer Business Location listed below.

3.Contract Termination. This Retailer Contract may be canceled by Retailer upon twenty (20) calendar days prior written notice to GLC. If the CEO determines, in her/his sole discretion, that cancellation, denial, revocation, suspension or termination of this Retailer Contract is in the best interest of GLC, the State of Georgia or the public welfare, the CEO may cancel, deny, revoke, suspend or terminate this Retailer Contract upon written notice to Retailer; provided, however, Retailer shall be entitled to a hearing on such cancellation, denial, revocation, suspension or termination in accordance with the Act and the Rules and Regulations; provided, further, that the CEO may temporarily suspend Retailer’s rights under this Retailer Contract without prior notice, pending any prosecution, hearing or investigation, in accordance with the Act. In addition to the foregoing, GLC may immediately cancel, deny, revoke, suspend, terminate, or refuse to renew this Retailer Contract for any of the reasons set forth in Exhibit A on the next page hereof.

4.Ticket Sales, Retailer agrees to sell lottery Tickets for all the games authorized by GLC, in GLC‘s sole discretion, and only at its

Retailer Business Locations listed below for which GLC has issued a Certificate of Authority under this Retailer Contract. Retailer agrees that it shall sell no other lottery Tickets in the State of Georgia, except those provided to it for sale by GLC. Retailer agrees that it shall adopt safeguards to assure that it will not sell lottery Tickets or pay prizes to persons under the age of 18 years. Retailer agrees that it shall sell lottery Tickets only at the prices, and only subject to the terms and conditions, fixed by GLC unless prior written authorization is received from the CEO in each instance. In accordance with the amounts specified in the Act and the Rules and Regulations, as full and complete compensation under this Retailer Contract, GLC will pay Retailer Commissions and other compensation for lottery Tickets sold and for winning lottery Tickets paid by Retailer.

5.Electronic Funds Transfer. Retailer shall have a fiduciary duty to preserve and account for all proceeds from the sale of lottery

Tickets collected by it and shall be responsible and liable for all such proceeds. All proceeds from the sale of lottery Tickets and all other funds due the GLC shall constitute a trust fund in favor of the GLC until paid to the GLC. Subject to the Act and the Rules and Regulations, Retailer agrees. (i) to maintain for the purpose of this Retailer Contract a separate bank account in the name of the Retailer as "Trustee for the Georgia Lottery Corporation”, with a bank acceptable to GLC which is a member of an automated clearing house association; (ii) to deposit daily into that bank account all proceeds from the sale of lottery Tickets and other funds due the GLC; (iii) to authorize GLC to initiate Electronic Funds Transfer (EFT) to and from that account for the net settlement due from the sales of GLC lottery Tickets; and (iv) that sufficient funds shall be available in the designated account on the dates specified by GLC to cover the amounts due GLC, as determined by GLC.

6.Prize Payments. During its normal business hours, Retailer agrees to immediately validate and pay all lottery Tickets winning prizes up to and including $600 for all lottery games that it is authorized by GLC to sell, in accordance with the Act and the Rules and Regulations. Such payment for winning Tickets shall not be in amounts greater or less than the amounts authorized by GLC, and shall never be subject to restrictions or conditions other than those imposed by GLC.

7.Promoting Sales. Retailer agrees to prominently display, in locations accessible to the public, point‑of‑sale advertising and other public information material and supplies provided from time to time by GLC and its Vendors and suppliers. Retailer agrees to attend all training sessions, as requested from time to time by GLC. In order to assist Retailer with sales of lottery Tickets, GLC and its Vendors and suppliers may provide certain equipment (such as Lottery Terminals, Ticket dispensers, Ticket vending machines, play stations, etc.) to be held in the custody and control of Retailer without any transfer of ownership of such equipment to Retailer; Retailer agrees to return any such equipment and supplies upon request of the owner and agrees to be financially liable and responsible for the use, preservation and protection of such equipment and supplies, normal wear and tear excepted.

8.Acceptance and Return of Instant Tickets, Subject to the conditions and reporting requirements more fully set forth in the

Rules and Regulations: (i) each Retailer shall have a fiduciary duty and responsibility to preserve and account for all Instant Tickets accepted from the GLC or its distributor, as well as cash proceeds from the sale of any lottery products; (ii) any Instant Tickets not properly accounted for by the Retailer upon termination of the Retailer Contract, upon demand by the GLC, or at the End of Game date for the corresponding Instant Game, regardless of the reason, shall be deemed to have been purchased by the Retailer; (iii)

Retailer shall be responsible for the full price of Instant Tickets, less any applicable Commissions, for all Instant Tickets which may be lost, stolen, or damaged after delivery to Retailer; and (iv) GLC will accept full and partial Instant Ticket Pack returns within (3) weeks of the termination, cancellation, suspension, revocation or non‑renewal of this Retailer Contract.

Page 1 of 2

Lottery Retailer ID:

Revised 4/1/18

9.Contract Changes. This Retailer Contract, including the Act and the Rules and Regulations, is the entire contract between GLC and

Retailer. This Retailer Contract may not be modified or amended except by a writing signed by both parties hereto or by amendment to the Act or the Rules and Regulations. To the extent of any conflict, the provisions of the Act shall govern the Rules and Regulations, and the Rules and Regulations shall govern the Retailer Contract.

IN WITNESS WHEREOF, GLC and the undersigned Retailer have executed, or caused their duly authorized representatives to execute, this Retailer Contract as of the date noted below.

1.Corporate or legal name (list the name of the legal entity which owns the business and files income tax returns):

2.Business Address where tickets are to be sold:

(Street)
(City, State & Zip)		GEORGIA LOTTERY CORPORATION
		GEORGIA LOTTERY CORPORATION

3. Printed Name and Title:		By:


4. By (signature):	5. Date:
		Gretchen Corbin, President and CEO
		Gretchen Corbin, President and CEO

EXHIBIT A to Retailer Contract

Notice of Specific Reasons for which a Retailer Contract may be Terminated

GLC may immediately cancel, deny, revoke, suspend, terminate, or refuse to renew any Retailer Contract if a Retailer or any of its owners:

a.violates a provision of the Act or of the Rules and Regulations; or

b.is or has been, or retains an employee involved in the sale of lottery Tickets who is or has been, convicted of a criminal offense related to the security or integrity of GLC or a lottery in any other jurisdiction; or

c.is or has been, or retains an employee involved in the sale of lottery Tickets who is, or has been, convicted of a gambling‑related offense, false statements, false swearing or perjury in this or any other jurisdiction or a crime punishable by more than one year of imprisonment or a fine of more than $1,000.00 or both unless the person’s civil rights have been restored and at least five (5) years have elapsed from the date of the completion of the sentence without a subsequent conviction of a crime described above; or

d.commits fraud, misrepresentation or deceit; or

e.provides false or misleading information to GLC; or

f.acts in a manner prejudicial to the security or integrity, or the public confidence in the security or integrity, of GLC; or

g.conducts business for the sole purpose of selling lottery Tickets; or

h.is delinquent in the payment of any federal, state or local taxes owed by it; or

i.changes any Retailer Business Location for which GLC has issued a Certificate of Authority under this Retailer Contract; or

j.fails to accurately or timely account for proceeds or prizes from the sale of lottery Tickets; or

k.fails to accurately or timely account for lottery Tickets received from GLC; or

l.fails to comply with any term of this Retailer Contract; or

m.fails to maintain a minimum level of sales, as established by GLC from time to time; or

n.substantially changes the ownership of Retailer without prior written notice to, or consent of, GLC; or,

o.files for or is placed in bankruptcy, receivership, insolvency or similar proceedings or fails to pay its debts as they become due; or

p.resides in the same household as any director, officer or employee of GLC; or

q.contracts with any other person or entity for lottery goods or services without the prior written approval of GLC; or

r.fails to meet any of the objective criteria established by GLC pursuant to the Act, or

s.is subjected to any material change, as determined to be material in the sole discretion of GLC, in any matter considered by GLC in entering this Retailer Contract; or

t.fails to maintain the designated account from which Electronic Funds Transfers (EFT) payments are to be made, fails to authorize GLC to initiate EFT transactions to and from such designated account, or fails to have sufficient funds available in such designated account on the dates specified by GLC.

Page 2 of 2

Revised 4/1/18

Dear Bank Representative:

Thank you for assisting our Retailer applicant. The Retailer must establish a separate electronic funds transfer (EFT) bank account in order to complete their Georgia Lottery Corporation application. This separate bank account must be specified “In Trust For the Georgia Lottery Corporation.”

Example:

XYZ, Inc.

D/B/A RCA Food Mart

In Trust for the Georgia Lottery Corporation

Please ensure that the account is not titled “Lottery Account.”

If you need any additional information, or have any questions, please contact Retailer Contracts Administration at 1-800-746-8546 option #4 then #7.

GEORGIA LOTTERY CORPORATION

Revised 4/1/18

Helpful Hints for completing the GLC Retailer Application Package

In order to facilitate the efficient processing of your GLC Retailer Application,

we’ve itemized some helpful hints for you.

Also, be sure to carefully read the Retailer Application instructions.

1.When making corrections, please use a single line to cross through the incorrect information. Then initial your correction.

Do not use white out. Applications with white out cannot be accepted.

2.Please ensure that all information on the application is accurate and complete before submitting to the Georgia Lottery

Corporation. An incomplete or inaccurate application will only slow down the processing of your application.

3.Please maintain a copy of the application for your reference during the application process.

4.Identification:

Please submit one of the following forms of valid identification. No other forms of identification can be accepted:

·Driver’s License

·Georgia Identification Card

·Identification Card issued by another state

·U.S. Armed Forces Identification Card

·U.S. Passport (must be signed)

·U.S. Resident Alien Card

5.Application Fee:

·The Application fee should be in the form of a cashier’s check, business check, or money order only.

·No personal checks or counter checks can be accepted.

·Please do not submit the application fee with a check from the Lottery EFT account.

6.Business Registration/Tax ID #s (Part 3 of the application):

·Federal Employers ID number: Obtain from the IRS by calling 1-800-829-0115. If you are a sole proprietorship, please use only your Social Security Number.

·All Corporations and Limited Liability Corporations must be properly registered with the Secretary of State.

·Further information can be obtained by contacting the Corporations Division of the Secretary of State at 404-656-2817 or by visiting their website at http://www.sos.ga.gov/index.php/corporations.

·All businesses must be registered with the Georgia Department of Revenue. Please call (404) 417-4445 to obtain registration information.

·Georgia State Tax Identifier Number & Georgia Sales Tax Number:

If already registered, this number can be found on your Georgia Department of Revenue registration certificate.

7.Legal Business Name/Ownership Type:

·Corporate or Legal Name: The legal entity which owns the business and files income tax returns.

·Store Name or DBA Name: The name of the business where tickets are sold. This name should match the Georgia Department of Revenue registration.

·Sole Proprietor: Your legally given name.

·Partnership: Partnership name should match the name on the Internal Revenue Service notification of the Federal Employers Identification Number.

·Corporation and Limited Liability Corporation: Please ensure that the legal business name and Secretary of

State registered name match.

Download Ga Lottery Application PDF Form

Form Data

Fact Number	Description
1	The Georgia Lottery Retailer application requires a fee of $125 for each business location, with $100 refundable if the application is not approved.
2	Applicants must list comprehensive business information including the legal entity name, business name, and contact details.
3	Every principal of the business needs to complete Part 2 of the application, providing extensive personal information.
4	A notarized statement affirming the accuracy of information and authorizing investigations is required from applicants.
5	An Electronic Funds Transfer Authorization is necessary, establishing a trust account for the Georgia Lottery Corporation.
6	Minority Business Ownership status is optional but requested, defined by the ownership's personal income reporting for Georgia tax purposes.
7	Applications must include business operating hours and be submitted with a specified fee via acceptable payment methods.
8	Personal identification for each owner, principal, shareholder, or officer is mandatory for the application process.
9	The retailer contract outlines the obligations of the lottery retailer, including compliance with the Georgia Lottery for Education Act and associated regulations.
10	The application and contract are subject to the laws and regulations of the State of Georgia, including the Georgia Lottery for Education Act (O.C.G.A. §50-27).

Instructions on Utilizing Ga Lottery Application

Filling out the Georgia Lottery Application form requires careful attention to ensure all information provided is accurate and complete. This process involves several parts, including business information, personal information of the business owners or principals, authorization for Electronic Funds Transfer (EFT), and signing the retailer contract. Before starting, ensure you have all necessary documents and information, including business and personal identification details, ready to streamline the process.

Part 1: Business Information
1. For each business location, enclose a payment of $125 using a Cashier’s Check, Business Check, or Money Order.
2. Enter the corporate or legal name of the entity owning the business on Line 1.
3. On Line 2, fill in the Store Name or "doing business as" (d/b/a).
4. Lines 3-8: Specify the business location, including street address, telephone number, city, state, zip code, and county.
5. If the mailing address differs from the above, complete Lines 9-12; leave blank if the addresses are the same.
6. Line 13 asks for the fax number, if applicable.
7. List each principal of the business on Line 14, adding extra sheets if required. Each listed individual must also complete Part 2.
8. Complete the certification and notarization requirement on Line 15.
9. Detail the business contacts on Line 16, providing names, titles, and phone numbers.
10. For businesses with majority ownership by persons of a minority race, fill in the optional information on Line 17.
11. List business hours for each day of the week on Line 18.
Part 2: Personal Information (Owner)
1. Make additional copies if more than one owner or principal needs to complete this section.
2. Lines 1-14: Provide detailed personal information for each owner or principal, including types of ownership, full names, contact details, social security numbers, and more.
3. If applicable, explain any "yes" responses on Line 15 on a separate sheet and attach.
4. Complete Lines 16-21 with additional personal details and attach a copy of an acceptable form of identification as listed on Line 22.
5. Complete, sign, and have the statement on Line 23 notarized.
Part 3: Electronic Funds Transfer Authorization
1. List the corporate or legal name on Line 1.
2. Enter required licensing numbers from the Georgia Department of Revenue on Lines 2-4.
3. Provide the Federal Employers ID Number or Social Security Number on Line 5, as appropriate.
4. Sign the authorization on Line 6 and ensure your bank’s representative completes and signs Line 7.
Part 4: Retailer Contract
1. Complete and sign page 2 of the Retailer Contract, representing your agreement with the terms set forth by the Georgia Lottery Corporation.
2. Ensure each member of an LLC or Partnership involved also completes and signs this section if applicable.

Once all parts of the application are completed and the necessary documents are attached, submit the application along with the required fee to the address provided. Ensure all information is accurate and true to the best of your knowledge, as any discrepancies might lead to delays in the processing of the application or its outright rejection.

Obtain Answers on Ga Lottery Application

What is the application fee to become a Georgia Lottery Retailer, and is any part of it refundable if the application is not approved?

The application fee to become a Georgia Lottery Retailer is $125 per business location. If the application for a business location is not approved by the Georgia Lottery Corporation, $100 of the $125 fee will be refunded to the applicant.
What information is required for the business in Part 1 of the application?

Part 1 requires details such as the legal name of the entity owning the business, the store name, the business location including address and telephone number, and the mailing address if different. It also asks for the fax number, a listing of each principal of the business, business contacts, an optional declaration of minority business ownership, and the business hours for each day of the week.
What information is necessary for each principal of the business in Part 2 of the application?

For each principal, personal information including the type of ownership, full name, sex, place of birth, title, race, percentage of ownership, date of birth, contact details, and social security number must be provided. Additional questions regarding residency, any criminal convictions, tax delinquencies, and bankruptcy filings are also included. Identification must be provided, and the section concludes with a consent and authorization for the release of personal background information.
What is the Electronic Funds Transfer Authorization section about in the application?

Part 3 requires the business to authorize electronic funds transfers to and from a designated bank account for the net settlement of lottery sales. It requires the business entity's name, various Georgia-specific tax and business identifiers, and the Federal Employers ID Number for partnerships and corporations, or a Social Security Number for sole proprietors. The section needs to be signed by the retailer and a representative of the depository institution.
How does one complete the Retailer Contract in Part 4?

Part 4 of the application includes signing and agreeing to the retailer contract with the Georgia Lottery Corporation. This requires acknowledging the rules and regulations, agreeing to the term and conditions for ticket sales, and making arrangements for the electronic funds transfer. Additionally, it includes commitments to selling only authorized lottery tickets, prize payments obligations, and promoting lottery sales effectively.
What forms of identification are accepted with the application?

Accepted forms of identification include a Driver's License, Georgia Identification Card, Identification Card issued by another state, U.S. Armed Forces Identification Card, U.S. Passport, or U.S. Resident Alien Card.
Who needs to complete Part 2 of the application?

Every owner, shareholder, member, and officer of the business must complete Part 2 of the application. Additional copies of the form should be made if necessary to accommodate all individuals.
How are business hours indicated in the application?

Business hours are indicated by specifying the opening and closing times for each day of the week, from Sunday through Saturday, in the designated section of the application.
What is the importance of the optional minority business ownership section?

The optional minority business ownership section allows businesses that are majority-owned by individuals of minority races to identify themselves as such. While not mandatory, completing this section can provide benefits under certain Georgia statutes and may influence consideration of the application.

Common mistakes

Applying to become a Georgia Lottery Retailer requires careful attention to detail. Inadequate or incorrect submissions can delay or impair the application process. Here are ten common mistakes made when filling out the Georgia Lottery Application form:

Not including the required fee: Failing to submit the application with the required $125 fee per business location can lead to immediate rejection.
Incomplete business information: Leaving out essential details like the business name, address, or contact information can cause significant delays.
Incorrect or missing principal information: Every principal of the business must complete Part 2 of the application. Overlooking this requirement can invalidate the application.
Misunderstanding the minority business ownership section: Not correctly completing the optional minority ownership section or misunderstanding its requirements can lead to incorrect classification.
Business hours not specified: Failing to list the operating hours for every day of the week can result in incomplete application status.
Incorrect or incomplete personal information: Personal details of each owner, shareholder, member, and officer are crucial. Any inaccuracies or omissions can cause processing delays.
Misidentification: Not attaching a copy of an acceptable form of identification for each individual listed in Part 2 can stall the application process.
Bank account information errors: Electronic Funds Transfer (EFT) authorization requires precise banking details. Errors in this section can prevent financial transactions necessary for lottery operations.
Failing to complete the retailer contract correctly: The Retailer Contract in Part 4 must be fully completed by each member of an LLC or Partnership, as required. Inaccuracies or incomplete information here can lead to legal and contractual issues.
Not using a cashier’s check, business check, or money order for the fee: Attempting to use an unauthorized payment method for the application fee can cause the application to be rejected outright.

Applicants must carefully review the entire application packet before submission to ensure all information is accurate, complete, and in compliance with the Georgia Lottery Corporation's requirements. Taking the time to double-check each part can save time and prevent unnecessary setbacks in becoming a Georgia Lottery Retailer.

Documents used along the form

Applying to become a Georgia Lottery retailer is an exciting step towards expanding the services offered by a business. However, alongside the Georgia Lottery Application form, there are several other forms and documents that are often needed to complete the application process. It’s important to have a clear understanding of each to ensure a smooth and successful application.

Personal Identification Documents: For each owner, shareholder, member, and officer of the business, a copy of a valid form of identification is required. Acceptable forms include Driver's License, State Identification Card, Passport, or Resident Alien Card.
Electronic Funds Transfer Authorization Form: This verifies the account set up for transactions with the Georgia Lottery Corporation. It includes bank details and authorization for debit and credit entries for lottery ticket sales and settlements.
Bank Verification Letter: Accompanying the Electronic Funds Transfer Authorization, a letter from the bank confirms the account details and the establishment of an account in trust for the Georgia Lottery Corporation.
Business License(s): Proof of current business licensure, such as a General Business License, Alcohol License, or Sales Tax License, is necessary to demonstrate legal operation within the state.
Proof of Minority Business Ownership (if applicable): For businesses claiming minority ownership, documentation verifying the business as minority-owned as defined by Georgia statutes is required.
Tax Identification Number Documentation: This includes the Federal Employer Identification Number (FEIN) for corporations and partnerships or Social Security Number (SSN) for sole proprietors.
Financial Statements or Business Plan: While not always required, providing financial statements or a detailed business plan can support the application by demonstrating the financial health and planning of the business.

Being thorough and providing complete and accurate documentation will greatly assist in the application process to become a Georgia Lottery retailer. Each document plays a crucial role in establishing the business's eligibility and readiness to undertake the responsibilities that come with selling lottery tickets. Remember, the goal is not only to expand the business's offerings but also to contribute to the Georgia Lottery's mission of raising funds for education in the state.

Similar forms

Business License Application: Similar to the Ga Lottery Application form, a business license application requires detailed business information including the legal name, DBA (doing business as) name, business location, and the contact information of the entity applying. Both forms often require information about the business owners and their personal details to ensure eligibility and compliance with regulations.
Vendor Registration Form: This form typically collects similar information about a business wanting to provide goods or services, including business and personal information of the owners or principal officers. Like the Ga Lottery Application form, it may include details about business operations and authorization for background checks to ensure the integrity of the vendor.
Alcohol License Application: This shares similarities with the Ga Lottery Application form in terms of providing detailed business information, ownership details, and operational specifics such as business hours. Both applications might require information regarding certification and compliance with state laws, including for minority-owned businesses.
Sales Tax Registration: Requires applicants to provide detailed information about the business, including the type of business, owner information, and business location. Both the sales tax registration and the Ga Lottery Application form collect financial information and may require electronic funds transfer (EFT) authorizations for transactions.
Employment Identification Number (EIN) Application: Similarity lies in the requirement to list detailed ownership and operational information. Both applications require the identification of principals in the business and may serve as a prerequisite for filing tax returns or other financial operations within the business structure.
Credit Application for Business Account: Both documents require comprehensive business and owner information, including financial standing and operations details. They may also include terms and conditions pertaining to financial transactions, such as Electronic Funds Transfer Authorization in the Ga Lottery Application form.
Franchise Application Form: Similar in requiring detailed business information, ownership structure, and financial information. Both the Ga Lottery Application and franchise applications assess the suitability of the business for operating under a larger corporate or organizational structure, sometimes including checks for legal and financial compliance.
Notarized Affidavit for Professional Accreditation: While serving different purposes, both types of documents require notarization and personal identification details, including the verification of the information provided through background checks or professional accreditation processes.

Dos and Don'ts

Filling out the Georgia Lottery Application form is a crucial step for businesses looking to become lottery retailers. To ensure a smooth process and increase the likelihood of approval, here is a list of dos and don'ts to consider:

Things You Should Do:

Provide accurate and complete information: Ensure that all sections of the application are filled out in detail and accurately reflect your business information and personal details of each principal involved.
Attach all required documents: Follow the instructions carefully and attach any additional documents that are requested, such as identification for each principal and documentation for the Electronic Funds Transfer Authorization.
Review the application for errors: Before submission, thoroughly review the application form to correct any mistakes or incomplete sections.
Sign and notarize the application where required: Ensure that the application is signed by an authorized person and that all statements requiring notarization are properly notarized.
Pay the required fee with an acceptable payment method: Submit the application along with the specified fee using one of the accepted payment methods (Cashier's Check, Business Check, or Money Order).

Things You Shouldn't Do:

Leave sections blank: If a section does not apply to you, indicate this with "N/A" (Not Applicable) instead of leaving it blank to avoid the appearance of an incomplete application.
Provide false or misleading information: Accuracy is crucial; providing false information can lead to the rejection of your application or termination of the retailer contract if discovered later.
Forget to attach required documentation: Failing to include necessary documents can delay the processing of your application or result in a denial.
Use an unaccepted payment method for the fee: Ensure you use one of the specified forms of payment for the application fee to avoid processing delays.
Ignore notarization requirements: Not having the required sections notarized can invalidate your application or significantly delay the approval process.

Adhering to these guidelines will help ensure that your application to become a Georgia Lottery Retailer is processed efficiently and without unnecessary delays.

Misconceptions

Addressing misconceptions about the Georgia Lottery Application Form requires clarity and specificity to ensure all potential retailers understand the process and requirements. Here are seven common misconceptions and their respective truths:

Every applicant must pay a non-refundable fee. A common misconception is that the application fee is entirely non-refundable. However, the Georgia Lottery Corporation (GLC) refunds $100 of the $125 application fee if the application is not approved.
Minority ownership information is mandatory. While the GLC encourages businesses with majority minority ownership to disclose this information, providing these details on the application is optional, not mandatory.
Personal information of business principals is optional. It's a misconception that providing detailed personal information for each owner, shareholder, member, and officer is optional. The reality is, the GLC requires comprehensive personal information for each principal to process the application effectively.
Electronic Funds Transfer (EFT) authorization can be general. Some believe that a general EFT authorization is sufficient. Contrarily, the retailer must establish a specific bank account “In Trust for the Georgia Lottery Corporation”, and that account's details must be precisely filled out in the application.
The application process is only for retail stores. A misconception exists that only traditional retail stores can apply. In reality, the GLC welcomes applications from a wide range of business types, including bars, lounges, hotels, and various non-retail establishments, as laid out in the Retailer Application Instructions.
Once approved, the contract is permanent. Some applicants mistakenly believe that once approved, their retailer status is permanent. The retailer contract is actually subject to annual renewal, at the sole discretion of the GLC, and can be terminated under certain conditions.
The Retailer Application does not require legal or financial advice. Another common misconception is that the application process is straightforward and doesn't necessitate any professional advice. Since the application involves legal and financial commitments, particularly in areas like EFT authorization and the handling of lottery proceeds, it may be prudent for applicants to seek advice to ensure compliance and understanding of all obligations.

Dispelling these misconceptions is crucial for ensuring that all prospective Georgia Lottery retailers have a clear understanding of the application process, requirements, and ensuing responsibilities.

Key takeaways

When completing and using the Georgia Lottery Application form, there are several key points to consider:

The application fee is $125 for each business location, with $100 refundable if the application is not approved by the Georgia Lottery Corporation.
Applicants must provide comprehensive business information, including the name of the entity owning the business, business address, and contact details.
Each principal of the business must also complete part of the application.
The application requires notarization, ensuring the information provided is accurate and truthful.
A section is dedicated to minority business ownership, encouraging inclusivity though its completion is optional.
Applicants must list business hours, providing a clear schedule of operation.
Personal information of each owner, partner, member, and officer must be submitted, supporting a thorough review process.
Disclosure about any criminal offenses, delinquency in state obligations, or bankruptcy filings is required to assess eligibility.
An Electronic Funds Transfer (EFT) authorization part is included, necessitating financial details for lottery transactions.
A Retailer Contract must be completed, outlining compliance with laws, regulations, and financial responsibilities related to ticket sales and prize payments.

Handling the Georgia Lottery Application form requires attention to detail, honesty in disclosing personal and business information, and an understanding of the financial commitments involved. By following these guidelines, applicants can navigate the process more effectively.

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