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Form Cpr - Concert Promoter Registration Application - Alaska Department Of Community And Economic Development

CPR

State of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

Concert Promoter Registration

P.O. Box 110806, Juneau, Alaska 99811-0806

(907) 465-2695

E-mail: license@dced.state.ak.us

CONCERT PROMOTER REGISTRATION APPLICATION

Nonrefundable application fee - $215

Registration fee - $375

The actual company name under which you will be doing business in Alaska (dba):

Complete Mailing Address:

Complete Physical Address:

City

State

ZIP Code

City

State

ZIP Code

Business Telephone:

OWNERSHIP - Check applicable box and provide complete names, addresses, and U.S. social security numbers

of owner, all partners, or corporate officers, whichever is appropriate.

Sole Proprietorship

Partnership

Corporation

Federal Employer I.D. #

Social Security Number

(For Sole Proprietor

Name

Address

and Partners)

PROFESSIONAL CONDUCT

Have you or the business had any license, registration, or permit denied, cancelled

or revoked in any state?..............................................................................................................

Yes

Is any such action pending? .......................................................................................................

Yes

If “yes,” provide the following information:

Name and Address of Government Agency

Nature of Action

(Indicate against whom

Date of

Name

City

State

action was taken)

Action

DEPARTMENT USE ONLY

Registration No. :

Issue Date:

Expiration Date:

12/31/

(1)

CONTINUED ON REVERSE

08-4075 (Rev. 1/00)

Form Cpr - Concert Promoter Registration Application - Alaska Department Of Community And Economic Development

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