Required fields are marked with asterisks (*)

Lottery License Eligibility Questionnaire (Page One)

This questionnaire must be completed fully and submitted to our licensing officer with the required documents uploaded and attached to this online form. A paper version of this questionnaire is available at the Municipal Office located at 2249 Loop Road, Wilberforce. If you require any further information please contact the licensing officer at 705-448-2981 ext. 422.

Multiple Signatures Required

Page Two of this form will requires that digital signatures be provided by three members of your organization. It is suggested that you do not attempt to complete this form until all individuals are present and available to provide a signature on the online form.

Collection of Personal Information

Personal information collected on this Lottery Licence Eligibility Questionnaire is obtained under the authority of the Municipal Act, 2001, the Criminal Code of Canada, and the policies of the Alcohol and Gaming Commission of Ontario (AGCO). This information will be used to assess organizational eligibility, administer the municipal lottery licensing program, and maintain related records. Personal information will be protected in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Questions about the collection, use, or disclosure of this information should be directed to the Municipal Clerk’s Office.

Organization Details

Registered Name of Organization

Operating Name (if different)

Business Address

Contact Name

Contact Phone Number

Contact Email Address

Website Address

Is the Organization incorporated as a non-profit organization with Ministry of Consumer & Business Services (Ontario)?

Yes

Is the Organization registered with Revenue Canada as a charity?

Yes

How long has your organization been providing services?

What category best describes your organization?

Relief of Poverty

Advancement of Education

Advancement of Religion

Other Charitable Purposes Beneficial to the Community

Please list and describe the specific programs and services your organization delivers and the associated cost for each. (Do not restate your mandate or mission statement.) (To provide funds to a bursary, it must be a registered bursary.)

Please list and describe the various programs and services your organization donates lottery proceeds to and the associated amounts for each.

Approximate total number of members in your organization:

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

Date of fiscal year-end:

Please indicate the last date of filing:

Does your organization currently manage and conduct any gaming events (lotteries) within the Municipality or other Municipalities?

Yes

Has your organization ever had a license revoked or refused?

Yes

Lottery Trust Account Information

For the purpose of lottery licensing, all organizations must have a lottery trust account. Please provide the required information about your organization's account below.

Name of Financial Institution:

Financial Institution Address:

Trust Account Number:

Date Opened:

License Delivery

Municipal staff will not disclose Lottery License numbers by phone, nor will licenses be faxed or emailed. Staff will mail licenses if time permits.

Would you like to pick up the License?

Yes