Form 04-071 - Amended Gaming Permit Application - Alaska Department Of Revenue - 1999

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State of Alaska

See instructions on

1999 Amended Gaming Permit Application

Alaska Department of Revenue

Income and Excise Audit Division

back of form.

AS 05.15.020

PO Box 110420

Juneau, Alaska 99811-0420

ORGANIZATION INFORMATION

Federal EIN

Permit Number

Organization Name

Telephone Number

COMPLETE ONLY IF THERE IS A CHANGE IN ADDRESS

Mailing Address

Fax Number

City

State

Zip Code

E-mail Address

ADDITIONAL TYPE OF GAMES (check only those games you are adding. For definitions see AS 05.15.690)

Bingo

Raffles & Lotteries

Pull-Tabs

Contest of Skills

Dog Mushers Contest

Fish Derbies

Sled Dog Race Classic

Rain Classic

Snow Machine Classic

Other _______________________________

NEW PERSON IN CHARGE OF GAMES. Persons must be designated active members of the organization, or an employee of the municipality.

New Primary Member Name

New Alternate Member Name

Effective Date of Change

Social Security Number

Daytime Phone Number

Social Security Number

Daytime Phone Number

Mailing Address

City, State and Zip Code

Has the primary member taken and passed the test?

Yes

Has the alternate member taken and passed the test?

Yes

Permit number under which the test was taken.________________________

ADDITIONAL ACTIVITY CONDUCTED BY ORGANIZATION

Facility Name

Physical Location

Game Type

Is Facility

Owned

Leased

Donated

CHANGE OF VENDOR (Pull-Tabs are the only games a vendor can conduct) Vendor Registration and Fee must be attached.

Name of Vendor

Physical Location

Add

Delete

CHANGE OF OPERATOR

Name of Operator

Physical Location

Game Type(s)

Operator's License Number

Add

Delete

CHANGE TO OR FROM MULTIPLE-BENEFICIARY PERMITTEE

Name of MBP

Physical Location

Game Type(s)

MBP Number

Add

Delete

THESE QUESTIONS MUST BE ANSWERED. (If you answer yes to either question, please submit the persons name and position of responsibility.)

Yes

Has any member of managment 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

Does any member of managment or any person who is responsible for gaming activities have a prohibited financial interest

as defined by 15 AAC 160.954 - 959?

We declare under penalty of unsworn falsification, that we have examined this application, including any attachment, and that to the best or our knowledge and

belief, it is true and complete. We understand that any false statement made on this applicaitonor any attachments is punishable by law.

Primary Member Signature

Printed Name

Date

President or Vice President Signature

Printed Name

Date

A copy of this application must be sent to all applicable municipalities and boroughs.

04-071 (revised 10/98)