Retailer Change of Information - Mississippi Lottery 幸运168®飞艇开奖预测网-Mississippi Lottery全国统一历史记录预测

Complete the form below to change information submitted on the Retailer Application. Do NOT use this form to change ownership. This form must be completed by an owner OR an authorized contact.

Comments

This field is for validation purposes and should be left unchanged.

Full name of Individual filling out this form:(Required)

First Last

Retailer ID:(Required)

Full Business Name:(Required)

Last 4 digits of Owner's Social Security Number for Verification(Required)

Only the Retailer Owner can submit changes.

Store Information to be Changed / Updated:

Only fill in fields below that need to be changed or updated.

Store Name

Phone #

Store Hours:

Physical Address

Street Address Address Line 2 City ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP Code

Contact Name

First Last

Contact Phone #

Contact Email

Owner Information to be Changed / Updated:

Only fill in fields below that need to be changed or updated.

Owner HOME Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner MAILING Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner Mobile Phone #

Owner Home Phone #

Owner Work Phone #

Owner Email

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