Form 0405-847a - Amended Operator License Application - 2013
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Alaska
847A
2013 Amended Operator License Application
Operator Information
Operator License #
Phone Number
Fax Number
EIN
SSN
Operator First Name
M.I.
Operator Last Name
Email
Complete only if there is a change in address.
New Mailing Address
City
State
Zip Code
Change of Location(s) of Activity
You must provide proof of liability insurance for each location you add.
Facility Name
Facility Type (check one)
Game Type(s)
Add
Delete
Owned
Leased
Donated
Physical Address
City
State
Zip Code
Facility Name
Facility Type (check one)
Game Type(s)
Add
Delete
Owned
Leased
Donated
Physical Address
City
State
Zip Code
Change in Contracted Permittees
List permittees for whom you will conduct gaming activities.
Permit #
Name of Organization
Game Type(s)
Add
Delete
Permit #
Name of Organization
Game Type(s)
Add
Delete
Permit #
Name of Organization
Game Type(s)
Add
Delete
Managers & Supervisors
Provide the required information for each person who manages or supervises any of the licensed gaming activities as defined in AS 05.15.122. If more
than one change, attach a separate sheet.
Add
Employee First Name
M.I.
Employee Last Name
Social Security Number
Delete
Home Mailing Address
Home Phone Number
City
State
Zip Code
Position Title
Legal Questions
These questions must be answered, If you answer Yes to either question, 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 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 conflict of interest as
defined by 15 AAC 160.954?
I declare, under penalty of unsworn falsification, that I have examined this application, including any attachments, and that, to the best of my
knowledge and belief, it is true and complete. I understand that any false statement made on the application or any attachments is punishable by law.
With my signature below, I agree to allow the Department of Revenue to review any criminal history I may have in accordance with 15 AAC 160.934.
Operator Signature
Printed Name
Date
DEPARTMENT USE ONLY
One copy of the completed application must be sent to all applicable municipalities and boroughs.
Date Stamp
See instructions for mandatory attachments.
847A
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-847A Rev 04/16/13
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