Application for the Retail Agent under the Maharashtra state lottery

ANNEXURE-I

Application Form

Application for the Retail Agent under the Maharashtra state lottery

regulation Act-2000-Part- I (Rule 5(4)

To,

Commissioner of State Lottery,

Maharashtra State, Mumbai-400 032.

Dear Sir/ Madam,

I desire to act as an Retail Agent for the sale of Maharashtra State

Lottery Tickets given by the government from time to time. I am giving my

particulars as below:-

2. a) Name :

b) Full Residential Address :

c) Father‘s Name :

d) Date of birth :

e) Educational Qualifications :

f) Full Address of proposed :

place for sale of Tickets

g) Area Available :

h) Details of current business :

(if any)at the proposed

place of Businessi) Type of ownership :

j) Mobile / Telephone No. :

k) Email address :

3. I declare that I will lift the maximum tickets from the Sewri office/

Wholesale Agent appointed by the State Government.

4. I declare that I will take all efforts to maximise the sale of

Maharashtra State Lottery draws.

5. I declare that I have read the Rules and Regulation of the agent

appointment. I/we shall abide by the rules and regulation regarding the agent

appointment. In case I/we selected as agent, I/we agree and abide by all

rules.

6. If I/we selected as an agent I/we shall deposit Rs. 200/- for Identity

Card/ Licence.

7. I/we are not convicted or punished under any offence.

8 I/we declare that the above information/fact is correct and true

Signature of applicant

Place:

Date :

Enclosure :

1. Permanent Address Proof

2. Educational Qualification

3. School Leaving Certificate/ Birth Certificate

4.2 Passport Size Photo

5. Recommendation letter.Recommendation Letter

I know Mr./Ms__________________________ who has applied

for retail lottery Agent for Maharashtra State Lottery. The

applicant is literate and bears no criminal background. I

recommend his/her appointment as a retail Agent for selling of

lottery tickets. I take the responsibility of the above facts given in

the application and also with respect to any irregularities which

may be done by the applicant.

Signature of the

recommending authority

(MLA, Corporator, Nagar Parishad Councillor, Member of Gram

Panchayat, Zilla Parishad, Panchayat Samiti, Special Executive

Magistrate, Gazetted Officer, Wholesale Agent, Bank Officer,

Principal of School, College, Notary, )