Retailer Application

Please contact the Lottery offices with questions on filling out your application at 307.432.9300.
You may also email dstevens@wylotterycorp.com.

Application Type*
- New Retailer Contract
  Please allow a minimum of 15 minutes to complete. At the bottom of this application, you will have the opportunity to provide notes and additional information about your business(es).

Applicant Information*

Please enter the primary applicant’s information.

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Is the business a Sole Proprietorship?*
Yes

No
Is the Sole Proprietor's information different than the applicant information above?
Yes

No
Is the business a Partnership?
Yes

No
How many partners are there?
How many locations or businesses are you applying for?

Owner/Partner Information #*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #1*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #2*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #3*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #4*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #5*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #6*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #7*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #8*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #9*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Owner/Partner Information #10*

First Name*
Last Name*
Date of Birth*
mm/dd/yyyy
Social Security #*
######### (no dashes)
Email Address*
Business Phone*
xxx-xxx-xxxx
Other Telephone
xxx-xxx-xxxx

Physical Address*

City*
State*
ZIP Code*
xxxxx (5 digit)

Driver's License Number*
State of Driver's License*

Retail Business / Location Information # *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 1 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 2 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 3 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 4 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 5 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 6 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 7 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 8 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 9 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 10 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 11 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 12 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 13 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 14 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 15 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 16 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 17 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 18 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 19 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 20 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 21 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 22 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 23 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 24 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 25 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 26 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 27 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 28 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 29 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Retail Business / Location Information # 30 *

Federal Employee ID Number*
XX-XXXXXXX
When filing taxes with the IRS, what is the Owner/Company name filed under?*
Legal Business Name*
Person Responsible/Liable for the Business*
Business Phone*
xxx-xxx-xxxx
DBA Business Name (if different)
Responsible Party Email Address*
Other Phone*
xxx-xxx-xxxx
Street Address*
- City*
- County*
- State*
- ZIP Code*
  xxxxx (5 digits)
Legal Business Type*
Schedule C

Partnership

S-Corp

C-Corp

Sole Proprietor

Limited Partnership

LL Partnership

Unincorporated Association

Not for Profit

LLC

Type of Business Applying for WyoLotto Terminal*
Convenience Store with Gas

Convenience Store w/o Gas

Gas Station

Liquor Store

Drug Store

Grocery Store

General Merchandise

Hotel/Motel

Bar/Restaurant

Truck Stop

Co-op

Lumber Yard

Tobacco Store

Feed Store

Check Cashing

Hardware Store

Eateries

Coffee Shop

Gift/Novelty

Pawn/Thrift

Not for Profit
Business Hours (Open to Close)*

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Both a Start time and End time selection are required. Examples: 6am-11pm or Open 24hr-Open 24hr

Vendor Hours (If Different from Business Hours)

Operations and Sales
When did the business open?*
MM/YYYY
Provide your average annual customer count/foot traffic*
Provide annual sales amount reported to the IRS for your last business year.*
If new business, report sales to-date.
Liquor License and Business Info

Does this location hold a liquor license?*
Yes

No

What type of liquor license does this location hold?*

Full

Bar

Restaurant

County/Malt

Beverage/Temp

Local Liquor License #	State Liquor License #

Has the liquor license ever been revoked/denied/suspended?*

Yes

Please explain why your license was revoked/denied/suspended.

Type of Building*
Free-Standing

Strip Mall

Mall

Office Building

Applicant Questionnaire*

If you answer “yes” to any of the following questions, provide an explanation in the space below.

A.
Yes

No
Within the last 10 years, have you been convicted of a felony in this state or another jurisdiction?*

B.
Yes

No
Have you been convicted of any fraud, unlawful gambling activity, false statements, false swearing, perjury, embezzlement or identity theft in this or another jurisdiction?*

C.
Yes

No
Within the last 5 years, has the business (as listed in Step 1) operated under a different DBA name? Different location? (please explain below under additional information)*

D.
Yes

No
Have you ever received penalties with the taxes or business related activities?*

E.
Yes

No
Is the sole proprietor, partner, shareholder for the corporation (owning more than 10% of the stock), a director, or an officer under the age of 18?*

F.
Yes

No
Have you ever had a Lottery or gaming license/contract revoked/suspended/terminated in any state?*

G.
Yes

No
Within the last 7 years, has the business filed any form of bankruptcy, whether voluntary or involuntary? Have you as a principal owner/person in any business filed for any form of bankruptcy, whether voluntary or involuntary? Is there any plan or intention to file any form of bankruptcy? If you answer “yes” to any question here, provide an explanation in the space below.*

H.
Yes

No
Is the business inaccessible to individuals with disabilities as may be required under Title III of the Americans with Disabilities Act?*

I.
Yes

No
Within the last 5 years, has your business or business employee violated Wyoming Statute 302 by selling tobacco, or Statute12-6-101 by selling alcohol to an underage person(s)?*

Additional Information*

Please enter any additional information that may be relevant to your application, or explanations to the above questionnaire.

Signature*

Lottery agrees to keep the information submitted in this Application confidential and to not publicly or privately disclose such information, unless necessary for Lottery operations or otherwise required by law.

I hereby certify that I am authorized either as the applicant or authorized to act on behalf of the application. I certify that the information provided to the Wyoming Lottery Corporation is true and complete. I understand and consent to an investigation of my personal/business credit history, business and personal financial records, criminal history, and any other matter pertaining the the authenticity of statements made in this application process; this authorization includes the use of personal identifying information for the purposes stated in this paragraph. I understand and consent to inspection by any law enforcement official or duly authorized state lottery official without a warrant or other process, of my premises to determine whether I am complying with the provisions of the Wyoming Lottery Laws and Wyoming State Statutes. I further understand that a false answer to any of the foregoing can subject the applicant to denial, suspension or revocation of this contract. I certify under penalty or perjury that all of the information in this Retail Application is complete and correct to the best of my knowledge and belief.

Terms and Conditions*

By clicking “I Accept” and submitting your application, you agree to be legally bound by the terms and conditions of the application and agree that you are signing this agreement electronically. You agree that your electronic signature shall have the same legal effect as your handwritten or manual signature. You are expressly encouraged to print and/or save a copy of this consent to electronically sign and to print and/or save a copy of your application.

I Accept

E-Signature*
Type your name as you would sign.
Date*
Business Title*

Retailer Application

Please contact the Lottery offices with questions on filling out your application at 307.432.9300. You may also email dstevens@wylotterycorp.com.

Please contact the Lottery offices with questions on filling out your application at 307.432.9300.
You may also email dstevens@wylotterycorp.com.