Lottery Application Montana Clear Form LOTAPP Rev. 07-09 General Information 1. Quota Area Applying For:_______________________________________ (Required) 2. Transaction: (choose one)  New City Beer  New “Floater” All-Beverages  New All-Beverages Please Note: Only one lottery application per person will be accepted. “Person” as defined in ARM 42.12.401 means any individual, firm, partnership, limited liability company, corporation or association. 3. Legal Applicant/Owning Entity______________________________________________________________ (Please do not use “Doing Business As”) Mailing Address__________________________________________________________________________ City, State, Zip___________________________________________________________________________ Contact Person____________________________________ Daytime Contact Phone____________________ If not filing as an individual, please list all individuals with 10% or more ownership interest on the statement on the back of this form. Floater Section “Floater” means an all-alcoholic beverages license that may be transferred to a new location outside the quota area for which it was originally issued. This type of license cannot be mortgaged or sold for 5 (five) years after the transfer. A floater license which is issued as the result of a lottery will have a gaming restriction. If applying for a “Floater” All-Alcoholic Beverages license, answer the following: • • Has the applicant applied for a “Floater” All-Alcoholic Beverages lottery within the previous 12 months? (If you answered “yes” to this question, you do not qualify for entry in the lottery)  Yes  No Does the applicant have any ownership interest in an All-Alcoholic Beverages license?  Yes  No (If you answered “yes” to this question, you do not qualify for entry in the lottery) • The applicant has provided with this application an irrevocable letter of credit from a financial institution that guarantees available credit in the amount of $100,000.  Yes  No (“Irrevocable letter of credit” means a letter of credit in which the issuing bank guarantees that it will not withdraw the credit or cancel the letter. A letter of credit may not be modified or revoked without the customer’s consent.) Include a copy of the letter of credit with the application. If no letter of credit is attached with this lottery application, the application will be disqualified. Please Note: A license transferred pursuant to a lottery after July 1, 2007, to a quota area outside the quota area for which it was originally issued, is not eligible to offer gambling under Title 23, chapter 5, part 3, 5, or 6. A successful lottery applicant for a “floater” license is required to begin business within one year of the lottery. *** Return to: Montana Department of Revenue, Liquor Control Division, PO Box 1712, Helena, MT 59624-1712 American LegalNet, Inc. www.FormsWorkFlow.com Ownership Information (includes Corporations, LLC’s, LLP’s and Partnerships) The stockholders, members/partners are (please print): Name Address Social Security Number Date of Birth Number of Shares/ Percentage of Ownership The officers and directors of the corporation are (please print): Name Address Title All APPLICANTS are required to sign and complete the section below: I,_ _________________________________________________________ , declare under penalty of false swearing that the Print Name information on this corporate statement is true and complete. Signature__________________________________________________________ Date_ ____________________________ Declaration and Affidavit If my application is drawn in the lottery, I understand that I must submit a completed license application and the appropriate fees within 30 days (60 days for a “floater”) of being notified that I was the successful applicant. I further understand that information concerning ownership on this application must be consistent with the license application and supporting documents or I will be disqualified. For example, if you complete this application as an “individual,” and are the successful applicant, your subsequent license application must also be as an individual. Important: You must return this lottery application by the deadline set in the publication notice. If the application is not complete, it will be disqualified. For information concerning the deadline for the specific area where you are applying, please call us at (406) 444-6900 or (866) 859-2254. Each lottery applicant will be notified of the drawing results. Signature__________________________________________________________ Date_ ____________________________ Printed Name_ ________________________________________ Title_ _________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com