First Name:


Phone Number:


Email Address:

Last Name:


Alternate Phone Number:

Business Name:


Address:

City:

State:
AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

Do you own this business?     Yes    No        For how long?   

What type of business is it?   

How many locations are there?   

What were last year's lottery sales?   

Is this a neighborhood store?   

What is your customer demographic?   

Do you have any space constraints?     Yes    No

Do you have internet access?     Yes    No

With what provider?           What type is it?    DSL Cable Wireless Dial-Up Other/Don't Know

Reference 1:
Name:


Reference 2:
Name:

 
Phone Number:


 
Phone Number:

Why are you interested in Sweepstakes?