Form 08-4075 - Concert Promoter Registration Application Packet (Page 4 of 7) in pdf

Form 08-4075 - Concert Promoter Registration Application Packet Page 4

Part III: PROFESSIONAL CONDUCT

The following question must be answered. A “Yes” answer may not automatically result in license denial. If you

answer “Yes” to the question, please explain dates and circumstances on a separate, signed and dated piece of

paper, and send copies of any supporting documents that are applicable (court records, etc.).

Have you or your business had any professional license, registration or permit denied,

revoked, suspended, or otherwise restricted, conditioned, or limited or have you

surrendered a professional license, been fined, placed on probation, reprimanded,

disciplined, or entered into a settlement with a licensing authority in connection with

a professional license you have held in any jurisdiction including Alaska and including

that of any military authorities or is any such action pending?

YES

Part IV: BONDING

The following is provided pursuant to the requirements of AS 08.92.030:

 Surety Bond

Escrow account with

 Time Certificate of Deposit

or Passbook Account

Bank Name and Location

 Cash Deposit

Account Number

ATTACH DOCUMENTS EVIDENCING THE ABOVE OBLIGATION - DOCUMENTS MUST BE ORIGINALS.

I certify that the information in this application and the supporting documents supplied by me are true and correct to

the best of my knowledge. I understand that any false or misleading information may result in failure to obtain, or

subsequent revocation of, a registration to promote concerts in Alaska.

SIGN HERE

Signature of Applicant

Title

Date

SUBSCRIBED AND SWORN TO before me on

(date).

Signature of Notary Public

Notary Public, State of

NOTARY SEAL

My Commission Expires:

All information submitted with this application is considered public information unless required by state or federal

law to remain confidential. If additional information of a confidential nature is required, you will be notified in

writing. License information, including mailing addresses, is available on the division’s website at

under License Search.

08-4075 (Rev. 06/11/13)

(2)

Form 08-4075 - Concert Promoter Registration Application Packet Page 4