Form 04-847 - 2000 Operator License Application As 05.15.122
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1
2Alaska Department of Revenue
State of Alaska
Income and Excise Audit Division
Check one:
2000 Operator License Application
PO Box 110420
New
AS 05.15.122
Juneau, AK 99811-0420
Renewal
Telephone 907.465.2320
This form is also available on the Intenet at
OPERATOR INFORMATION
Federal EIN or Social Security Number
License Number
Alaska Business License Number
Operator Name
Permit Number (if applicable)
Business Name
Telephone Number
Mailing Address
Fax Number
City
State
Zip Code
E-mail Address
Contact Person
Title
Contact Telephone Number
OPERATOR IS (check one):
Individual
Municipality
Qualified Organization
LOCATION(S) OF ACTIVITY. You must provide proof of liability insurance for each location.
Facility Name
Physical Location
Game Type(s)
Telephone Number
THESE QUESTIONS MUST BE ANSWERED. (see instructions)
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 - 959.
I declare under penalty of unsworn falsification, that I have examined this form, including any attachments, and that to the best of my knowledge and belief is true
and complete. I understand that any false statement made on this document or any attachments is punishable by law.
Operator Signature
Printed Name
Date
X
License Fee $500.
Make check payable to the State of Alaska
For Department Use Only
VALIDATION NUMBER
PMD:
Security $__________________
Operator Test
Insurance $_________________
See instructions for mandatory attachments.
Form 04-847 (Rev 09/99) Front
A copy of this application must be sent to all applicable municipalities and boroughs.
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