License Change Request Form FY27

SeamlessDocs

checkbox_zzd
New Field
New Field
New Field
New Field
New Field
New Field
New Field
New Field
New Field
New Field
New Field
New Field
Signature HereClick to Sign
New Field
checkbox_wvI
New Field
New Field
New Field
Reviewed submitted formfor accuracy and completeness
Submitted MAC form to DCI for gaming equipment removal
Will update retailer information in BOS on effective Date
NO
Confirmed future instant ticket deliveries have been canceled
Checked for allocations in transit report and ticket issued_1
Signature HereGrant Alexander Will Sign Here
Reviewed Retailer Inventory Report for eligible instant ticket returns
Confirmed Sales Rep has returned all eligible instant tickets
Finance Department can settle any outstanding instant tickets on report
Signature HereNikki Mathis Will Sign Here
10/01/2026
10/01/2026
Signature HereWeusi Berry Will Sign Here
10/01/2026
Checked for outstanding balances reconciliations or financial obligations
Reviewed possible refunds adjustments or account updates
Settle outstanding instant ticket games if any
Signature HereDaryl Vann Will Sign Here
10/01/2026
Reviewed submitted formfor accuracy and completeness_1
Confirmed all department tasks are completed
NO_1
Signature HereJoshua Johnson Will Sign Here
Lottery account temporally closed Will reactivate on effective date
10/01/2026
x

Additional Signatures Required