Monte Carlo
Lottery Licence Application
Please allow two weeks for the processing of your application
Applicant
Applicant Information
Organization Name: _________________________________________
Mailing Address: ___________________________________________
_________________________________________________________
City/Town: ________________________________________________
Province: ____________________ Postal Code: __________________
Phone: _____________________ Fax: ________________________
Email: __________________________________________________
1) Has your organization previously held
a lottery? Yes No
If Yes, what was the last licence number? ___________________
2) Is your organization a registered charity
with the Charities Directorate? Yes No
If Yes, what is the registration number? ___________________
3) Is your organization incorporated as a
non-profit organization? Yes No
If Yes, what is the incorporation number? ___________________
Proposed Use of Proceeds
Provide details as to how proceeds will be used: (Attach a separate sheet if necessary.)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Monte Carlo Event(s) Location
Name of the premises: _________________________________ The premises is owned by: ___________________________________
____________________________________________________ ________________________________________________________
Street Address: _______________________________________
____________________________________________________ Rent: $ _____________ per _____________
City/Town: ___________________________________________
Province: ____________________________________________ Is the premises a licenced liquor outlet? Yes No
To be signed by two Principal Officers of the Organization
We certify that all information and documents supplied are correct and the organization has authorized us to make this application.
Name: ___________________________________________________
Position: _________________________________________________
Address: _________________________________________________
_________________________________________________________
City/Town: ________________________________________________
Province: _________________ Postal Code: ____________________
Phone (W): ________________ Phone (H): ______________________
Signature: ________________________________________________
Date: ______________________
Email: ___________________________________________________
Name: ____________________________________________________
Position: ___________________________________________________
Address: ___________________________________________________
__________________________________________________________
City/Town: _________________________________________________
Province: __________________ Postal Code: ____________________
Phone (W): _________________ Phone (H): ______________________
Signature: __________________________________________________
Date: ______________________
Email: ____________________________________________________
Organization RSN__________
Property RSN __________
Folder RSN _____________
Entered ______________
Office use
only
Personal Information contained on this form is collected by the Government of Newfoundland and Labrador and is
protected under the Access to Information and Protection of Privacy Act, 2015.
Monte Carlo Lottery Licence Application
Event(s) Date(s)
1) A single event to be held on _______________________________________
2) A series of events to be held during the period ____________________ to ____________________ for a total of __________ events.
Event Information
Admission
Number of Tickets Printed ________________________
Ticket Price $ __________________________________
Is there a door prize or ticket draw associated
with the purchase of the ticket? Yes No
If Yes, what is the value of the prize? $ _____________
and describe the prize(s): ____________________________
___________________________________________________
Wheel of Fortune Number of
Wheels per event
Ticket Wheel (cash or merchandise) _________________
Crown and Anchor _________________
Over and Under _________________
Other Wheels (please describe below) _________________
______________________ _________________
______________________ _________________
Monte Carlo Tables & Games Number of Tables/Games
per event
Roulette _________________
Blackjack _________________
Poker _________________
Horserace _________________
Other Games & Tables _________________
(please describe below)
______________________ _________________
______________________ _________________
______________________ _________________
Ticket Raffle
(Prize value per raffle cannot exceed $500) Yes No
Lotteries Trust Account Information
Event(s) Chair/Manager
Name of Bank of Financial Institution:
________________________________________________________
Type of account: __________________________________________
Person responsible for the event(s):
____________________________________________________________
Phone (W): ___________________ Phone (H): ______________________
Gaming Supplier(s)
Name of gaming supplier(s):
___________________________________________________________
Licence
Please indicate method of receiving your licence: _______ Fax ________ Email __________ Mail
The Licence will be mailed to your organization’s mailing address unless otherwise indicated.
Applications can be dropped off at any Service Centre; mailed to Consumer Affairs Division P.O. Box 8700 St. John’s, NL
A1B 4J6; faxed to (709) 729-6998, or (709) 637-2498, or emailed to:
appsconsumeraffairs@gov.nl.ca
Consumer Affairs Toll Free Number: 1-877-968-2600, or Locally (Mount Pearl) at (709) 729-2660.
Contact for Regional Offices: Corner Brook (709) 637-2445 (office) Fax: (709) 637-2498.
Reminder
This application is only to be used if applying for a Monte Carlo Table or Monte Carlo game.
The application must be signed by two principal officers of your organization. i.e. president, vice president, treasurer.
Any changes or amendments to the licence shall be requested in writing. A licence is not transferable.
A licence will not be issued for a Monte Carlo lottery event where the location of the event will be a commercial bar or tavern.
Please read the General Rules and the rules for Monte Carlo lottery before submitting your application. See Schedule “F”
September 2017
Service NL
Government of Newfoundland & Labrador
http://www.servicenl.gov.nl.ca