Caribbean Lottery Retailer Application
This form is an application for our retailer program.
Owner Informaition
Name
*
First Name
Last Name
Title
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Jurisdiction
*
Please Select
Anguilla
Antigua & Barbuda
St. Kitts & Nevis
St. Maarten
US Virgin Islands - St. Croix
US Virgin Islands - St. Thomas
Upload Proof of Address
*
Browse Files
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Choose a file
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of
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Identification Document Information
Identification Document Type
*
Please Select
Passport ID
National Identication Card
Driver's License
ID Number
*
Ownership
Title
*
Ownership Type
*
Please Select
Patnership
Company Publicly Held
Company Not Publicly Held
Association
Fraternal
Trust
Owned%
*
Primary Owner Name
*
Back
Next
Business & Tax Information
New Shipping Address
*
Please Select
Same as Physical Address
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Jurisdiction
*
Please Select
Anguilla
Antigua & Barbuda
St. Kitts & Nevis
St. Maarten
US Virgin Islands - St. Croix
US Virgin Islands - St. Thomas
Upload Proof of Address
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Tamis Number
*
Upload Business Registration Document
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Other Information
Trade Channel
*
Please Select
Unclassified
Gas Station
Convenience
Liquor & Drug Store
Social Trade
Trade Style
*
Please Select
None
Gas
Gas Service Station
Liquor Store
Gas No Service Station
Truck Stop
Brake Stop
Bar
Casino
Convenience (Gen)
Convenience (Petrol)
Convenience (Pharm)
Convenience/ Variety Store
Department Store
Drug Proprietary Store
Gas/ Service Station
Grocery (L)
Grocery (S&M)
Hotel/ Casion
Kiosk
Lottery Office
Lottery Office (Promo)
Lottery Office (Sales)
Lottery Office (Validate)
Non- Traditional
Non-Classified
Other
Other Non-Retail
Pharmacy
Restaurant
Restaurant/Bar
Rum Bar
Social Space (F&B)
Social Space (LVT)
Supermarket
Ticket Outlet Only
Wholesale Agency
Bakeries
Bagel Doughnut Shop
Tea Room
Specialty Coffee House
Location Contact
New Location Contact
*
Please Select
Yes
No
Contact Type
*
Please Select
Primary Contact
Supervisor
Manager
Job Title
*
Name
*
First Name
Last Name
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Jurisdiciton
*
Please Select
Barbados
Please verify that you are human
*
Signature
*
Submit
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