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Application Forms

Your Retailer Documents



This is where you’ll find a variety of documents associated with becoming a retailer. Please DO NOT complete any of these forms unless you have been assigned a Field Application Representative and they have asked you specifically to download these forms.

The forms you will be required to complete will be pre-populated specific to you and your entity and delivered to you by your Field Application Representative.

To begin the application process and get a Field Application Representative assigned to you, please contact the Field Application Support Specialist at 503-540-1136.

Application Checklist [download] (51KB PDF)
This document will show you the forms we require you to complete and other documents you must submit with your application. When you contact the Lottery about an application we will ask you a variety of questions and personalize an application checklist for you. Before you can submit an application you must provide all forms and documents listed on this checklist.

Retailer Contract [download] (165KB PDF)

Temporary Retailer Contract [download] (166KB PDF)
Some applicants may qualify for a temporary retailer contract. You can find the specific criteria in OAR Chapter 177, in Division 40 by selecting Retailer Contract Rule.

Application for Retailer Contract(Video+Traditional or Video only) [download] (98KB PDF)
Traditional Application Retailer Contract(Traditional only) [download] (94KB PDF)
All prospective applicants (as defined on OAR Chapter 177, Division 40) must complete one of these forms as part of an application for a Retailer Contract. Read the general instructions on these forms carefully. If you do not understand the requirements, please ask your Field Application Representative. All questions must be answered completely. Under Oregon Revised Statute 461.700, you are required to disclose all information relating to any criminal offense, traffic crime or violation; failing to do so will likely result in the denial of your application. The most common mistake applicants make on these forms is failing to disclose an arrest or conviction. If you make a mistake, please single line through the mistake, make the correction, then initial and date.

Personal Disclosure [download] (84KB PDF)
All Key Persons (as defined on OAR Chapter 177, Division 40) must complete a personal disclosure form as part of an application for a retailer contract. Read the instructions on this form carefully. If you do not understand the requirements, please ask your Field Application Representative. All questions must be answered completely. Under Oregon Revised Statute 461.700, you are required to disclose all information relating to any criminal offense, traffic crime or violation; failing to do so will likely result in the denial of your application. The most common mistake applicants make on this form is failing to disclose an arrest or conviction.

Gross Sales Report [download] (31KB PDF)
The purpose of this form is to provide the Lottery a monthly sales report for non-Lottery sales which include food, alcohol, non-alcoholic beverages and miscellaneous sales (Video Lottery only).

Statement of Funding
The purpose of this document is to inform the Lottery how much money is required for you to open and operate this business and where those funds come from. The Lottery may not contract with you if you do not have adequate funds to operate and maintain the business or if your funding is from a prohibited or an unacceptable source.

Minimum Financial Documents Required at Time of Application (28KB PDF)

Statement of Funding Form (62KB PDF)

Accessibility >>


Wheelchair Accessibility Information

Lottery games must be accessible to persons who use wheelchairs. This is a critical issue that has very specific and technical requirements. This document gives you some background information and specifications from the Federal Americans with Disabilities Act, Accessibility Guidelines (ADAAG), State of Oregon, Structural Specialty Code, Chapter 11 Accessibility, and Oregon Transportation Commission. Contact the Lottery’s Accessibility and Compliance Officer for any questions you may have. Call: (503) 540-1047, or 1-800-766-6789, extension 1047.

Wheelchair Accessibility Letter (69KB PDF)

Wheelchair Accessibility Guidelines (1.35MB PDF)

Wheelchair Tax Incentives (9.21KB PDF)

Wheelchair Accessibility Certificate (111KB PDF)

The purpose of this form is to ensure your business is compliant with OAR 177-40-070.

Additional Forms


Organization Change Application [download] (47KB PDF)
If you are a retailer and you are making a change - hiring a new manager, selling stock in your company, electing new officers, reorganizing to a corporation or other entity - you will need this form. Please give us a call when you’re preparing to make this type of change and we’ll assist you through the process.

Video Lottery Retailers – Option A/B [download] (6KB PDF)
Once each business year, your Oregon Lottery® retailer contract gives Video LotterySM retailers the opportunity to choose a compensation option (A or B) for the upcoming business year. If you choose to stay with your current commission option no action is needed. If you wish to choose a new Video Lottery compensation option you must submit this signed option election form 60 days before the business year begins.

4506-T Tax Form [download] (92KB PDF)
The purpose of this form is for you to show the Lottery that you are compliant with federal taxes.

ODR Form [download] (48KB PDF)
The purpose of this form is for you to show the Lottery that you are compliant with state taxes.

Authorization to Release Financial Records and Credit, Character and Personal History Information. [download] (for entity, 32KB PDF). [download] (for key person, 32KB PDF).
The purpose of these forms is for the Lottery to obtain financial records, credit, character and personal history information on you and/or your company.

EFT Banking Form [download] (126KB PDF)
Authorization agreement for electronic fund transfer/payments.

Entity Disclosure Form [download] (71KB PDF)
The purpose of this form is to ensure the Lottery has accurate information on an entity owner of the contract holder.

Lessee Form [download] (53KB PDF)
The purpose of this form is to ensure the Lottery has accurate information on the person or entity that is leasing a portion of the retailers business.

Location Data Form [download] (58KB PDF)
The purpose of this form is to ensure the Lottery has accurate information on the operating hours and access hours of the business and contact persons information.

Personal Guaranty Form [download] (32KB PDF)
The purpose of this form is to ensure the Lottery will be guaranteed payment of funds by an individual of the entity.

Personal Resubmission Form [download] (93KB PDF)
You may use this form if you have submitted a complete Personal Disclosure Packet to the Oregon Lottery within the past 12 months. If it has been more than 12 months, you must submit a complete new Personal Disclosure Packet.

W-9 Form [download] (46KB PDF)
The purpose of this form is to ensure the Lottery has your correct federal taxpayer identification number for reporting purposes.

Links


Useful business related links for retailers.

Workers Compensation
http://www4.cbs.state.or.us/ex/wcd/cov/search/index.cfm

Oregon Secretary of State, Corporations Division
http://www.filinginoregon.com/index.htm

Oregon Liquor Control Commission
http://www.olcc.state.or.us

2011 - 13 Lottery Fund
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County by County Fund Distribution


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Oregon Lottery • 500 Airport Road SE, Salem, OR, 97301 • PO Box 12649 Salem, OR, 97309-0649 • www.oregonlottery.org
Phone: 503-540-1000 • Fax: 503-540-1001 • Email: lottery.webcenter@state.or.us