Illinois Lottery Retailer Application Packet

Additional Signatures: Retailer Contract for Sale of Lottery TicketsWrite the owner, officer, member or partner information, completing one entire section for each person. If needed,please attach Additional Signature pages. All owners/officers/partners/members must be at least 18 years old.Business NameCLast Name First Name MI Job Title % OwnershipHome Street AddressCity State ZIP CountyProperty listed here isOwned RentedSSN Spouse’s SSN Date of BirthSexMaleFemaleRace (optional)Driver’s License NumberHome Phone Mobile Phone Alternate PhoneSignatureDateDLast Name First Name MI Job Title % OwnershipHome Street AddressCity State ZIP CountyProperty listed here isOwned RentedSSN Spouse’s SSN Date of BirthSexMaleFemaleRace (optional)Driver’s License NumberHome Phone Mobile Phone Alternate PhoneSignatureDateELast Name First Name MI Job Title % OwnershipHome Street AddressProperty listed here isOwned RentedCity State ZIP CountySSN Spouse’s SSN Date of BirthSexMaleFemaleRace (optional)Driver’s License NumberHome Phone Mobile Phone Alternate PhoneSignatureDateIDL-30 Retailer Contract for Sale of Lottery Tickets (R 07-2013)