Required fields are marked with asterisks (*)

Port Hope Lottery Licence Questionnaire

Part One

Registered Name of Organization:

Operating Name (if different):

Address:

Telephone Number:

Fax Number:

Email Address:

Website:

Is the Organization incorporated as a non-profit organization with Ministry of Consumer & Business Services (Ontario)?

Yes

Please provide registration date & number:

Is the Organization registered with Revenue Canada as a charity?

Yes

Please provide registration date & number:

How long has the Organization been providing services?

What category best describes the Organization?

Relief of Poverty

Health and Welfare

Advancement of Religion

Advancement of Education

Other charitable purpose/benefit to the Community

Please list and describe the specific programs and services delivered by the Organization and associated cost(s): (DO NOT restate your mandate or mission statement)

Services

Cost

Cost

Approximate total number of members in the organization:

Date of fiscal year-end:

Please indicate last day of filing:

Does the Organization currently manage and conduct any gaming event (lotteries) within other Municipalities?

Yes

If yes, please indicate type of gaming event and which Municipality:

What type of gaming event?

What Municipality?

What type of gaming event?

What Municipality?

What type of gaming event?

What Municipality?

What type of gaming event?

What Municipality?

Please include the name(s) and address of Supplier registered under Gaming Control Act, 1992.

For the purpose of lottery licensing, all organizations must have a lottery trust account. Please complete the following information:

Name of Bank

Trust Account Number

Address:

Date Opened

Would you like to pick-up the Licence?

Yes

If YES, please provide telephone number we can call you once it's ready:

If NO, please provide contact name and mailing address:

Pursuant to the Municipal Freedom of Information and Protection of Privacy Act, the personal information contained in this form will be used solely for the purposes of determining eligibility for various licensing processes in the Municipality of Port Hope. The application forms part of the public record. Questions regarding this collection may be directed to the Municipal Clerk at 905.885.4544 or by email.

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Port Hope Lottery Licence Questionnaire

Part One