8/12/2019 Owner LocationB

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13. Place of Birth: City:

State: Country:

14. Height: 15. Weight: 16. Hair Color: 17. Eye Color:

18. Do you reside in the same household as any ofcer or employee of the Georgia Lottery Corporation? Yes No

19. Are you a vendor, employee or agent of any vendor of the Georgia Lottery Corporation? Yes No

20. Have you been convicted of a criminal offense related to the security or integrity of the lottery in this or any

other jurisdiction? Yes No

21. Have you been convicted of any illegal gambling activity, false statements, false swearing or perjury in this or

any other jurisdiction or convicted of any crime punishable by more than one year of imprisonment or a ne

of more than $1,000.00 or both? Yes No

22. Are you delinquent in taxes, fees or other obligat ions owed to the State of Georgia? Yes No

23. Have you led bankruptcy in the last seven (7) years? Yes No

24. Are you related to a COAM Class B License holder? Yes No

Note: If you answered Yes to any of the above questions, please explain on a separate sheet and attach to this application.

25. Personal Information Prepared by:

Name Title Date

Signature Print Name Date

STATE OF: COUNTY OF:

SWORN TO AND SUBSCRIBED BEFORE ME ON THIS DAY OF (MONTH) (YEAR)

Notary Public Seal and Signature: My Commission Expires:

Personal Identification (ID) is required to be presented to and verified by Notary Public. Type of ID: ID Number:

Revised May 2014

CLASS B LOCATION LICENSE ID#:PART 2 - Personal Information

Coin Operated Amusement Machine Application

GEORGIA LOTTERY CORPORATION P.O. Box 56927 Atlanta, GA 30343

1-800-746-8546 - OPTION #4 - Retailer Contracts Administration

This information must be completed for each of the primary

(top 10) owners, partners, and shareholders of the business.

1. First, Middle & Last Name of Owner or Principal: 2. M or F: 3. Title: 4. Race: 5. Date of Birth:

6. % of Ownership: 7. E-mail: 8. Primary Phone Number: 9. Alternate Phone Number: 10. Social Security Number:

11. Home Address:Address line 1:

Address line 2:

City: State: Zip Code:a.

b.

c.

d.

12. List all other names you have used, including nicknames, surnameother than your true name, or if female, furnish your maiden name:

First Middle Last

CONSENT AND AUTHORIZATION FOR RELEASE OF PERSONAL BACKGROUND INFORMATION:I hereby certify that the information contained on this form or otherwise submitted by me to the Georgia Lottery Corporation (GLC) in connection with this

Applicants application to become a Bona Fide Coin Operated Amusement Machine (COAM) licensee is true and correct in every respect. Specically, I certify thaI have reviewed both the Applicants Business Information Page(s) as submitted, and my own Owner Information Pages for this application, and I certify that theinformation contained therein is true and correct in every respect. I understand, agree and consent that GLC may make any and all investigations of my backgroundin order to satisfy the GLC requirements for qualication of the Applicant as a COAM Licensee, which investigations may include, without limitation, criminal historyrecord information, credit history records, tax records, public records and other ofcial records, and the investigation generally of any other matter relating to bothme and the Applicant being a COAM Licensee. As a potential COAM Licensee or a current COAM Licensee, licensed by the GLC, or as an owner of same, I amrequired to furnish certain information for use in determining my qualications. I hereby authorize GLC to request a credit report, conduct a criminal backgroundinvestigation, or conduct any other investigation as may be necessary to process my COAM Licensee Application. I authorize GLC to share any such information,privileged, condential or otherwise, necessary to consider the application to become a COAM Licensee. I further consent to allow GLC to use and share suchinformation in any and all manners consistent with all applicable laws and necessary to effectuate, administer or enforce all rights, orders and obligations arising outof the relationship between the Applicant and GLC. A photocopy of this release will be valid as an original thereof, even though said photocopy does not contain anoriginal writing of my signature. This release will expire upon the nal termination of the Applicants COAM License obligations to the GLC. I further understand and

acknowledge that providing inaccurate or misleading information is grounds for rejection of this application and suspension or cancellation of the COAM Licenseand may subject the Applicant and me to the penalties set forth in the Georgia Lottery for Education Act, O.C.G.A. 50-27-1, et seq.