Form 501A, Fantasy Contest Operator Personal Information Form (Commonwealth of Virginia, VDACS Office of Charitable & Regulatory Programs) Instructions

Enter the full legal name of the individual who is granting authorization on behalf of the entity.

Enter the entity's complete registered corporate name as it appears on legal documents.

Enter the entity's trade name or DBA if different from the corporate name, or leave blank if none.

Enter the official job title or position of the person signing the form for the entity.

Enter the date when the representative signed this authorization.

Enter the full physical street address where you lived (house number, street name, and apartment or unit number if applicable).

Enter the city of the physical address listed above.

Enter the state for the address above (you may provide the two-letter state abbreviation or full state name).

Enter the approximate start and end dates you resided at this address using month and year (for example: mm/yyyy - mm/yyyy).

Enter the full physical street address (house number, street name, and apartment or unit number if applicable) for the residence.

Enter the city where the B-2 address is located.

Enter the state for the B-2 address (use the standard two-letter state abbreviation if space is limited).

Enter the approximate residency period for this address as a month/year range in the format mm/yyyy – mm/yyyy (start – end).

Enter the full physical street address for B-3, including street number, street name and apartment or unit number if applicable.

Enter the city name where the B-3 address is located.

Enter the state for the B-3 address (either the standard two-letter abbreviation or the full state name).

Enter the approximate time period you resided at the B-3 address as a start and end month and year in the format mm/yyyy – mm/yyyy.

Enter the street address where you resided for this entry, including house number, street name and apartment or unit number if applicable.

Enter the city of the residence listed on this line.

Enter the state of the residence (full name or two-letter postal abbreviation).

Enter the approximate start and end dates you lived at this address in mm/yyyy – mm/yyyy format (for example, 06/2018 – 08/2020).

Enter the start and end month/year for this employment as mm/yyyy – mm/yyyy (for example, 01/2019 – 06/2021).

Enter the full corporate or employer name for this job or position.

Enter the employer's street address (street number and name, and suite or unit if applicable).

Enter the city where the employer's physical address is located.

Enter the state or province (abbreviation or full name) where the employer is located.

Enter the title or position you held at this employer during the listed time period.

Provide a brief summary of your primary duties and responsibilities in this role.

Enter the inclusive start and end month/year for this employment using the format mm/yyyy – mm/yyyy (for example: 01/2019 – 12/2020).

Enter the full legal name of the corporate entity or employer for this employment entry.

Enter the employer's street address for this job, including building number, street, and any apartment or suite information.

Enter the city where the employer's address is located.

Enter the state where the employer is located (use the two-letter abbreviation or full state name).

Enter the job title or position you held at this employer.

Provide a brief description of your primary duties and responsibilities in this position, highlighting key tasks performed.

Enter the start and end month and year you worked at this employer in the format mm/yyyy – mm/yyyy (for example, 01/2018 – 06/2020).

Enter the full legal or corporate name of the employer or entity for this employment entry.

Enter the employer's full physical street address (street number, street name, and suite or unit if applicable).

Enter the city where the employer's physical address is located.

Enter the state or territory where the employer's physical address is located (abbreviation or full name).

Enter the job title or position you held with this employer during the stated time period.

Provide a brief summary of your primary duties and responsibilities in this position.

Enter the primary telephone number where you can be reached, including the area code and any necessary extension.

Enter the primary email address you use for official contact regarding this application.

Check this box if you have been subject to any administrative proceeding or investigation by any gaming or tax-related regulatory agency and you are attaching an explanation sheet detailing the facts and circumstances.

Check this box if you have never been subject to any administrative proceeding or investigation by any gaming or tax-related regulatory agency.

Check this box if you have been arrested, detained, charged, indicted, convicted, pleaded guilty or nolo contendere, or forfeited bail for any misdemeanor involving gambling, financial crimes, or any felony, and you are attaching an explanation sheet with details.

Check this box if you have never been arrested, detained, charged, indicted, convicted, pleaded guilty or nolo contendere, or forfeited bail for any misdemeanor involving gambling, financial crimes, or any felony.

Check this box if you have been delinquent or in dispute with a government agency over the payment of any debt or tax in the past ten years and you are attaching an explanation sheet detailing the facts and circumstances.

Check this box if you have never been delinquent or in dispute with a government agency over the payment of any debt or tax in the past ten years.

Check this box if you have been a party to any lawsuit (other than divorce) and are including an explanation sheet detailing the facts and circumstances.

Check this box if you have not been a party to any lawsuit (other than divorce).

Check this box if you are currently a known party to any administrative proceeding, criminal case, investigation, or lawsuit (other than divorce proceedings) and you are including an explanation sheet with details.

Check this box if you are not currently a known party to any administrative proceeding, criminal case, investigation, or lawsuit (other than divorce proceedings).

Check this box if you are or have knowingly been professionally associated with persons convicted of a felony or related offenses and you are attaching an explanation sheet detailing the facts and circumstances.

Check this box if you are not currently and have never knowingly been professionally associated with persons convicted of a felony or related offenses.

Check this box if you have requested a criminal history search to be conducted by the appropriate authority in each jurisdiction where you lived during the previous ten years and those jurisdictions will send the results to the address on this form.

Check this box if you have NOT requested those criminal history searches and are attaching an explanation sheet detailing the reason.

Check this box when you have attached a signed copy of the 'Authority to Release Information' form to this application.

Check this box if you (and your spouse/immediate family acting in concert) do NOT beneficially own or control 15% or more of the equity ownership of the fantasy contest operator applicant and do NOT have the power to vote or cause the vote of 15% or more.

Check this box if you (or your spouse/immediate family acting in concert) DO beneficially own or control 15% or more of the equity ownership of the fantasy contest operator applicant or DO have the power to vote or cause the vote of 15% or more; complete the requested amount, percentage, and instrument details.

Enter the monetary amount of the ownership or financial interest you (or your immediate family) hold in the operator/applicant. Fill only if 'E-1 Yes, please provide the following:' is 'Yes'.

Enter the percentage of equity or voting interest you (or your immediate family) beneficially own or control in the operator/applicant. Fill only if 'E-1 Yes, please provide the following:' is 'Yes'.

Describe the form of the interest (for example, common stock, preferred stock, options, loan, membership interest or other instrument) that represents your ownership or control. Fill only if 'E-1 Yes, please provide the following:' is 'Yes'.

Check this box if during the previous ten years you had a business relationship with or financial interest in any fantasy-contest-related activity, business, or facility (other than the applicant or already disclosed) and you are including an explanation sheet identifying the relationship and financial details.

Check this box if during the previous ten years you did not have any business relationship with or financial interest in any fantasy-contest-related activity, business, or facility (other than the applicant or already disclosed).

Enter your legal first (given) name exactly as it appears on official documents.

Enter your legal middle name or middle initial as shown on official documents, or leave blank if you have none.

Enter your legal last (family/surname) name exactly as it appears on official documents.

Enter a legal suffix such as Jr., Sr., II, III, IV, Esq., etc., if applicable; otherwise leave this field blank.

Enter the mailing street address, apartment/suite number, or PO Box if different from your physical address. Fill only if 'Physical Address (Street)', 'City', 'State', 'ZIP / Postal Code', 'Country' is different from all Physical Address section fields (all fields).

Enter the city for your mailing address. Fill only if 'Physical Address (Street)', 'City', 'State', 'ZIP / Postal Code', 'Country' is different from all Physical Address section fields (all fields).

Enter the state or province for your mailing address (use the standard abbreviation if applicable). Fill only if 'Physical Address (Street)', 'City', 'State', 'ZIP / Postal Code', 'Country' is different from all Physical Address section fields (all fields).

Enter the postal ZIP or postal code for your mailing address. Fill only if 'Physical Address (Street)', 'City', 'State', 'ZIP / Postal Code', 'Country' is different from all Physical Address section fields (all fields).

Enter the country for your mailing address. Fill only if 'Physical Address (Street)', 'City', 'State', 'ZIP / Postal Code', 'Country' is different from all Physical Address section fields (all fields).

Enter the full printed name of the notary who is signing the document.

Enter the notary's official commission or commission registration number as issued by the state.

Enter the expiration date of the notary's commission.

Enter the day of the month on which the notary statement was sworn and subscribed.

Enter the month in which the notary statement was sworn and subscribed (e.g., January or Jan).

Enter the year in which the notary statement was sworn and subscribed.

Enter the name of the county or city where the notarization occurred.

Enter the name of the state in which the notarization took place.

Enter the applicant's country of citizenship or nationality.

Provide the applicant's Social Security Number as issued by the U.S. Social Security Administration.

Enter the applicant's gender identity (for example: Female, Male, Non-binary, or Other) as they wish it recorded.

Enter the applicant's date of birth.

Enter the street address of the physical location, including house/building number and street name and any apartment or suite number.

Enter the city where the physical address is located.

Enter the state or province for the physical address (use the standard two-letter state abbreviation if applicable).

Enter the ZIP or postal code for the physical address, including leading zeros if applicable.

Enter the country where the physical address is located.

Enter the date on which the signer executed or affixed their signature to this form.