Form 04-859 - Multiple-Beneficiary Permit Application - 1999
Download a blank fillable Form 04-859 - Multiple-Beneficiary Permit Application - 1999 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 04-859 - Multiple-Beneficiary Permit Application - 1999 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2State of Alaska
Alaska Department of Revenue
Check one:
Income and Excise Audit Division
1999 Multiple-Beneficiary Permit Application
New
PO Box 110420
AS 05.15.145
Juneau, Alaska 99811-0420
Renewal
Telephone (907) 465-2320
ORGANIZATION INFORMATION
Federal EIN
Permit Number
MBP Name
Telephone Number
Mailing Address
Fax Number
City
State
Zip Code
E-mail Address
TYPE OF GAMES (check all games that you will conduct. For definitions see AS 05.15.690)
Bingo
Raffles & Lotteries
Pull-Tabs
Contest of Skills
Dog Musher's Contest
Fish Derbies
Snow Machine Classic
Rain Classic
Other _______________________________
PERSONS IN CHARGE OF GAMES. Persons must be active members of the organization, or an employee of the municipality, designated by the organization.
Members may not be licensed as an operator, vendor, or employee of a vendor
Primary Member Name
Alternate Member Name
Social Security Number
Daytime Phone Number
Social Security Number
Daytime Phone Number
Mailing Address
Mailing Address
City, State and Zip Code
City, State and Zip Code
Has the primary member taken and passed the test?
Yes
No
Has the alternate member taken and passed the test?
Yes
No
Permit number under which the test was taken.________________________
Permit number under which the test was taken.________________________
MBP MEMBER APPLICANTS. All member applicants must (1) have a permit (2) have applied for a permit, or (3) submit all information required to qualify
for a permit in this permit year.
Permit Number
Name of Organization
Telephone Number
1.
2.
3.
4.
5.
6.
THESE QUESTIONS MUST BE ANSWERED. (If you answer yes to either question, please submit the person's name and position of responsibility.)
Yes
No
Has any member of management or any person who is responsible for gaming activities ever been convicted of a felony, extortion, or
a violation of a law or ordinance of this state or another jurisdiction that is a crime involving theft or dishonesty or a violation of
gambling laws?
Yes
No
Does any member of management or any person who is responsible for gaming activities have a prohibited financial interest
as defined by 15 AAC 160.954, 955 or 957?
I declare under penalty of unsworn falsification, that I have examined this application, including any attachment, and that to the best of my knowledge and belief, it
is true and complete. I understand that any false statement made on this application or any attachments is punishable by law.
Primary Member Signature
Printed Name
Date
X
VALIDATION NUMBER
Permit Fee
PMD:
$100
Make checks payable to the State of Alaska
See instructions for mandatory attachments.
A copy of this application must be sent to all applicable municipalities and boroughs.
04-859 (revised 10/98) front
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial