Application for renewal of registration as a video lottery siteholder

Step 1: Siteholder Information Step 1 of 3: Siteholder Information

Step 2: Contact Information

Step 3: Additional Details

* Indicates a required field

Siteholder Information

Category:

I Site (15-25 Video Lottery Devices) -$3,000

II Site (11-14 Video Lottery Devices) - $2,000

III Site (1-10 Video Lottery Devices) - $1,000

Legal name:

Business name (operating as):

Change in officers

In the last year, have there been any changes in the owners, co-owners, retailers or managers responsible for gaming of the registered video lottery siteholder?

Yes

If yes, provide the following information for each change (upload 1 attachment below): *

the name and position of the individual who has left or is being replaced; and
the name and position of the new individual.

You can upload TIF, TIFF, BMP, JPG, JPEG, GIF, PNG, PDF, DOCX or DOC files (max. 8000 KB).

After submitting this renewal form, the following individuals must complete a Gaming Control and Licensing Services Background check personal disclosure form :

new persons, i.e. owners, co-owners, retails or manages who have replaced those who previously held this role; as well as
owners, co-owners or manages whose information has changed since the last personal disclosure form that they submitted.