Change of Owner Form Type of Business(Required) Sole Owner Two or more partners National or Regional Retail Chain This field is hidden when viewing the formBusiness InformationBusiness Information Applicant Name(Required)Applicant Relation to Business(Required) General Manager Store Manager Owner Shareholder Partner Other Business Name(Required)Information Services Corp Entity Number(Required)Business Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) This field is hidden when viewing the formPROPRIETORSHIP: Sole Owner InformationOwner Information Owner Name(Required)Position/Title(Required)Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you own any other businesses with a Lottery Ticket Terminal?(Required) Yes No Please list the name of the business(es) and town(s):(Required)Business NameTown Add RemoveThis field is hidden when viewing the formCORPORATION: Corporate/Head Office InformationCorporate/Head Office Information Signing Authority Name(Required)(Person responsible for lottery portfolio with in corporate)Position/Title(Required)Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) This field is hidden when viewing the formPARTNERSHIP: Stakeholders/Owners InformationPartners – Stakeholder/Owner Information List all individuals with at least a 20 per cent stake in the company. Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you need to add another individual?(Required) Yes No Name(Required)Shareholding Percentage(Required)Please enter a number from 20 to 100.Position/Title(Required)Are you an authorized signatory?(Required) Yes No Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Do you own any other businesses with a Lottery Ticket Terminal?(Required) Yes No Please list the name of the business(es) and town(s):(Required)Business NameTown Add RemoveThis field is hidden when viewing the formRetail Location InformationRetail Location Information Retail Location Name(Required)Mailing Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Same as mailing address Street Address same as mailing address Street Address or Legal Land Description(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Hours of Business(Required)DayOpen (a.m.)Close (p.m.) Add RemoveWill the current on-site manager responsible for lottery change?(Required) Yes No On-site manager responsible for lottery(Required)NamePhoneEmail Add RemoveThe store location is:(Required) Owned Leased Lease Landlord Name(Required)Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) What are the future business plans for the location?(Required)Will any products or services change?(Required)Will any renovations to the location take place that will disrupt or move the lottery equipment?(Required) Yes No Please explain the details of the plans.(Required)This field is hidden when viewing the formDeclarationDeclaration Declaration(Required) By submitting this application, I certify that there are not misrepresentations or falsifications in the information stated in the application.