Form 0405-837 - Pull-Tab Distributor License Application - 2014
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837:08 30 13
Alaska
837
2014 Pull-Tab Distributor License Application
Distributor Information
Apply online at
If renewing, enter distributor license #
Alaska business license #
EIN
SSN
Primary Stockholder or Owner Name
Check one:
Sole proprietorship
Partnership
Corporation
Corporation Name
Owner Name (sole-proprietor only)
Business Name
Phone Number
Fax Number
Mailing Address
Contact Person
City
State
Zip Code
Email
Legal Questions
These questions must be answered
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?
Mandatory Attachments
Attach a list containing:
1. Physical address of each business location from which pull-tabs will be sold in Alaska.
2. Names, addresses, social security numbers and dates of birth of every stockholder or investor who possesses more than 10% interest in the
distributorship.
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.
Primary stock holder or owner’s signature
Printed Name
Date
License Fee is $1,000
DEPARTMENT USE ONLY
Validation#
One copy of the completed application must be sent to all applicable municipalities
and boroughs.
Date Stamp
Pay online with OTIS at or make check payable to State of Alaska.
New applicants must pay by check.
837
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-837 Rev 08/30/13
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