ONTARIO LOTTERY AND GAMING CORPORATION (OLG)

RETAILER APPLICATION

FOR OFFICE USE ONLY

✔
 New Retailer  Ownership Change ( Effective Date ) Terminal #

Work Req # Retailer Location # Owner Group #

APPLICANT INFORMATION:
Do you currently or have you in the past owned another OLG Lottery Location?
If Yes, please complete information below:

Retail Location #

Location Name:

Location Address:

OPERATING NAME OF STORE:

Physical Address: City: Prov: Postal Code

ON
If located in a Mall or Plaza, name of Mall or Plaza: Store Phone:

Mailing Address (If different than location’s address): City: Prov: Postal Code
PO Box:

Shipping Address (if different than location’s address) City: Prov: Postal Code

Main Lottery Contacts at this Location (Attach additional sheets as necessary):

Manager: Store Email Address:

Telesales: Principal Email Add.:

Hours of Business - Mon. Tue. Wed. Thurs. Fri. Sat. Sun. Holidays

OPEN A.M.

CLOSED P.M.

LANDLORD INFORMATION (If Applicable): Is there a landlord? YES NO

Name: Phone: Email:

Address: City: Prov.: Postal Code:

Additional Info:

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BUSINESS TYPE: CHECK AND COMPLETE ONE ONLY
LEGAL NAME OF BUSINESS:

 Individual, Sole Proprietorship

Owner’s Name: First Name Middle Name Last Name Personal Phone:

Home Address: Street : City: Prov.: Postal

Code:
Signature of Retailer:

Print Name of Witness (Must be 18 Years of Age or Older): Signature of Witness:

 Partnership (Attach additional sheets as necessary)

1. Partner’s Name: First Name Middle Name Last Name Personal Phone:

Home Address: Street : City: Prov.: Postal

Code:
Signature of Retailer Partner:

Print Name of Witness (Must be 18 Years of Age or Older): Signature of Witness:

2. Partner’s Name: First Name Middle Name Last Name Personal Phone:

Home Address: Street : City: Prov.: Postal

Code:
Signature of Principal:

Print Name of Witness (Must be 18 Years of Age or Older): Signature of Witness:

 Corporation (Attach additional sheets as necessary) I have the authority to bind the Corporation.
1. Principal’s Name: First Name Middle Name Last Name Personal Phone:

Home Address: Street : City: Prov.: Postal

Code:

Signature of Principal of Retailer

Print Name of Witness (Must be 18 Years of Age or Older): Signature of Witness:

2. Principal’s Name: First Name Middle Name Last Name Personal Phone:

Home Address: Street : City: Prov.: Postal

Code:
Signature of Principal:

Print Name of Witness (Must be 18 Years of Age or Older): Signature of Witness:

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 For Another Form of Entity
Entity’s Name: Personal Phone:

Address: Street : City: Prov.: Postal

Code:
Print Name of Authorized Signing Officer:

Signature of Authorized Signing Officer:

Print Name of Witness (Must be 18 Years of Age or Older): Signature of Witness:

APPLICATION ACKNOWLEDGEMENT
The applicant certifies that the information provided to the Ontario Lottery and Gaming Corporation (OLG) is true and
complete and that there are no misrepresentations or falsifications in the information stated, and the applicant undertakes to
immediately notify OLG in writing of any change in such information. Personal information on this form is collected under the
authority of the Ontario Lottery and Gaming Corporation Act 1999, and the Gaming Control Act 1992 for the principal
purposes of assessing the applicant’s suitability to sell OLG products and for compliance with law (including the Registrars
Standards for Gaming: Lottery Sector). If this application is approved the personal information collected may be used for
monitoring and enforcing compliance with OLG’s Retail Agreement, Retailer Policy Manual, Rules of Play and Prize Claim
policies. All information in this application will be retained in accordance with OLG’s record retention policies. If you are
providing information regarding any other person listed on this form, you represent, acknowledge, and agree that you are
doing so with his or her permission and that they have reviewed this application. If you have any questions you may
contact OLG Support Centre at 1-800-387-0104. OLG’s head office is located at 70 Foster Drive, Suite 800, Sault Ste.
Marie, Ontario, P6A 6V2.

I have received, reviewed and agree to the terms of the ONTARIO LOTTERY AND GAMING
CORPORATION RETAILER AGREEMENT AND RETAILER POLICY MANUAL.

Signature of Retailer: ____________________________________________________________

DATE: ____________________________

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PG 4 & 5 FOR OFFICE USE ONLY

BUSINESS CASE & PRESITE (If O/C, skip this page)

Store Classification (Grocery Store, Convenience, Gas with Convenience etc.)

Sales Specialist / Account Lead: DSM:

Type of Business Case: If 2nd Terminal, RL#

CorpCode: CorpName: CorpID: CorpDist:

Customer Display:
Installed in a Backershield? Size of CDU? 24"
Length of Pole? Orientation?

Ticket Checker:

Install: If Counter, ( ft from Terminal)

If Other,

Playstand Type: If Basic

Current Placement: If Counter, ft from Terminal)

If Other,

Moving to: If Counter,( ft from Terminal)

If Other,

Playstand Type: If Basic,

Is the Playstand being moved? If Yes, distance and date

Is the Playstand prepped for ticket checker?

Does placement of ticket checker adhere to AODA Guidelines?

Customer BCR Location:

Special Instructions/ Additional Comments & Equipment Layout:

Prepared by: Date:

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Wireless Jackpot Sign: Sign Type? Admart: Carmanah

Facing? Location?

Approval Received? Approved By?

Dip Switch Setting (Admart)

Mounting Hardware Required? Type?

Mounting point of WJS or Power Receptacle higher than 10 ft?

Merchandise:
Retailer has agreed to take the following merchandise items:
List the actual # of merchandise items required
Portrait Silent Seller A Frame / Hurricane Sign

Landscaped Silent Seller Lighted Sign

1/2 Silent Seller Temp Gift Card Holder

New Silent Seller with Lock Selection Slip Holder

Vertical Showcase

Instant Infinity Merchandiser

Please list any other merchandise items below:

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 PRE-AUTHORIZED DEBIT (PAD) PAYMENT PLAN FOR OLG RETAILERS
(RETAILER'S ACKNOWLEDGEMENT AND AUTHORIZATION)

Ontario Lottery and Gaming Corporation ("OLG") and the undersigned retailer of OLG products (the "RETAILER") agree as follows:

A. Moneys Are Property of OLG

1. All moneys received by the Retailer from the sale of OLG products and all moneys held by the Retailer for the payment of prizes on
behalf of OLG are moneys of OLG.

2. The Retailer holds all moneys received by the Retailer from the sale of OLG products and all moneys held by the Retailer for the
payment of prizes on behalf of OLG.

3. All moneys held by the Retailer for OLG shall, at such times, in such amounts and in such manner as OLG shall direct, be
deposited with the financial institution and in the Business Bank Account designated in section 5.

4. The retailer is required to have the OLG Pre-authorized Debit Payment Agreement (PAD) completed by the designated bank of the
applicant. A void cheque must accompany the completed PAD Form.

5. The retailer will deposit all OLG funds in the following

_____________________________________________ ______________________________________________
Business Bank Account Name Name of Financial Institution

_____________________________________________
Business Bank Account Number
_____________________________________________
Institution Transit Number
_____________________________________________
Institution Number
Financial Institution Domicile Stamp:
_____________________________________________
Street Number
_____________________________________________
Town/City Postal Code
_____________________________________________
Branch Telephone Number

B. Pre-Authorized Debit (PAD) Plan Authorization and Acknowledgements

6. The Retailer hereby authorizes OLG and the Financial Institution to debit the Business Bank Account for the purpose of obtaining
for the benefit of OLG all moneys belonging to OLG and collected on behalf of OLG by the Retailer until such time as written notice to
the contrary is given by the Retailer to OLG.

7. The Retailer acknowledges that this plan (“PAD”) is a business PAD (and that the transaction type will be identified by the code
“700-Business PAD”),and waives all pre-notification requirements.

8. The Retailer hereby authorizes that a debit, in paper, electronic or other form, may be drawn on the Business Bank Account by
OLG for each OLG invoice.

9. The Retailer acknowledges that provision and delivery of this authorization to OLG constitutes delivery of this authorization by the
Retailer to the Financial Institution.

10. The Retailer acknowledges that the Financial Institution is not required to verify that any purpose of payment for which the debit
was issued has been fulfilled by OLG as a condition to honouring a pre-authorized debit issued or caused to be issued by OLG on the
Business Bank Account.

11. Revocation of this authorization does not terminate any contract for goods or services that exists between the Retailer and OLG.
The Retailer's authorization applies only to the method of payment and does not have bearing on any such contract for goods and
services exchanged.

12. The retailer must allow OLG ten (10) business days prior to processing a cancellation or change to the Business Bank
Account by contacting our OLG Support Centre toll free at 1-800-387-0104.

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13. The Retailer acknowledges that the rules of the Canadian Payments Association governing pre-authorized debit plans require that
a pre-authorized debit may be disputed by the Retailer only under the following conditions:
a) the authorization was never provided to the payee (i.e., OLG);
b) the pre-authorized debit was not drawn in accordance with the payor's (i.e., the Retailer's) authorization;
c) the payor's authorization was revoked; or
d) the debit was posted to the wrong account due to invalid/incorrect account information supplied by the payee

14. The Retailer has certain recourse rights if any debit does not comply with this agreement. The Retailer has the right to receive
reimbursement for any debit that is not consistent with this PAD agreement. To obtain more information on your [my/our] recourse
rights, [I/we] may contact your [my/our] financial institution or visit www.cdnpay.ca.

15. The Retailer acknowledges that, in order to be reimbursed pursuant to section 14 hereof, a signed declaration to the effect that
either (a), (b), (c) or (d) of section 14 hereof took place must be completed and presented to the Financial Institution at the branch
where the Bank Account is located. Upon receipt of such declaration, duly signed by the Retailer, the Financial Institution will, up to
and including 10 days after the date the item in dispute was posted to the Business Bank Account, immediately reimburse this amount
to the Retailer.

16. The Retailer acknowledges that a claim on the basis that the Retailer's authorization was revoked, or for another reason indicated
in section 14 hereof, is a matter to be resolved solely between OLG and the Retailer when disputing any item after 10 days.

17. The retailer acknowledges understanding the terms and conditions of OLG PAD plan. OLG will debit the retailers Business Bank
Account bi-weekly each Tuesday and Friday unless otherwise communicated by OLG (i.e. statutory holidays). The retailer further
acknowledges receipt of a copy of this authorization as outlined in Section 6.3 of the Retailer Policy Manual.

18. The Retailer represents and warrants that all persons whose signatures are required to sign on the Business Bank Account have
signed this acknowledgement and authorization.

______________________________________________
Retailer Location Number * Those with signing authority on the account cannot sign as a
witness.
______________________________________________
Print name of Retailer
____________________________________________
______________________________________________ Witness
Signature of Retailer

______________________________________________
Print name of additional (if applicable)
____________________________________________
______________________________________________ Witness
Sign name of additional (if applicable)

Dated at ___________________________________ this ____________ day of ____________, 20 ____.

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Add a copy of a void cheque or Void Cheque form from bank here.