Lottery Licensing Eligibility Form

Name of organization:

Municipal address:

City/Town:

Province:

Postal code:

Email address:

Type of Lottery for which this application is being made (check one):

Bingo

Break-open / Nevada

Raffle / 50-50

Bazaar

Is the applicant incorporated as a non-profit organization in the Province of Ontario?

Yes

If yes, incorporation number:

Is the APPLICANT registered with Canada Customs and Revenue Agency as a charitable organization?

Yes

If yes, registration number:

Jurisdiction of incorporation:

How long has the organization been in existence?

How many persons comprise your bona fide membership?

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

Describe your organization’s aims and objectives:

Indicate the specific purpose(s) to which the lottery proceeds will be applicable.

The Applicant Organization Lottery Trust Account (if open at this time)
NOTE: It will be required at the time of application.

Name of financial institution:

Address of financial institution:

City/Town:

Province

Postal Code:

Account number:

Applicant's fiscal year-end date:

The designated member of the organization who will be responsible for keeping and maintaining records of all financial transactions pertaining to the licensed lottery activities:

Name:

Business address:

City/Town:

Province:

Postal code:

Telephone number (business):

Email address:

Names of bona fide members who will conduct one or more of the lottery events referred to on this application:

Name	Name
Name: 1.	Name: 6.
Name: 2.	Name: 7.
Name: 3.	Name: 8.
Name: 4.	Name: 9.
Name: 5.	Name: 10.

We, the undersigned, declare that all information provided in and with this statement is factual and correct.

Name of Principal Officer:

Title:

Date:

Name of Principal Officer:

Title:

Date:

I have read the Mandatory Documents Requirement, and agree to submit the required documents set forth in the checklist.

Mandatory Documents – Checklist to Determine Eligibility

In order to obtain a lottery licence, organizations must first be deemed eligible for licensing. Please submit the following documentations for review:

Incorporation Papers (Letters Patent)
Constitution and By-Laws
Notification of Charitable Registration (Canada Customs and Revenue Agency) (if applicable)
The most recent Registered Charity Information Return & Public Information Return, as submitted to Canada Customs and Revenue Agency (if applicable)
Financial Statement for Previous Fiscal Year (audited, where applicable)
Detailed outline of all programs/services provided in the previous year and specific costs incurred in delivery
Detailed outline of all programs/service currently provided and specific costs incurred in delivery
The current operating budget
Current Listing of the Board of Directors
Any other information that will assist in determining the charitable nature of the objects and purposes. This could include an annual report, correspondence relating to its charitable number for income-tax purposes, confirmation that it meets the reporting requirements of the Charities Accounting Act
The proposed use of proceeds, which must be consistent with the primary objects and purposes of the organization and of a charitable nature consistent with at least one of the four classifications of charitable purposes:
- The Relief of Poverty
- The Advancement of Education
- The Advancement of Religion
- Any Purpose Beneficial to the Community
  - The Nature of Culture and the Arts
  - The Nature of Health and Welfare
  - Sports Organizations
  - Public Amenities
  - Service Clubs

Information taken from the Alcohol and Gaming Commission of Ontario’s Lottery Licensing Policy Manual and Lottery Licence Terms and Conditions

Please bring the checklist documentation to the Township office at 636 St. Lawrence St, Winchester after you submit the online form.

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Lottery Licensing Eligibility Form