Form 853 - Pull-Tab Manufacturer License Application - 2013
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Alaska
853
2013 Pull-Tab Manufacturer License Application
Apply online at
Manufacturer Information
If renewing, enter manufacturer license #
EIN
SSN
Corporation Name
NAFTM member?
Yes
No
Business Address
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. The physical address of each business location from which pull-tabs will be sold to Alaska distributors.
2. The names, addresses, social security numbers and dates of birth of every stockholder or investor who possesses more than 10% interest in the
company.
3. Sworn statement - NAGRA standards. If not a NAFTM member, then complete and attach the sworn statement (form 095).
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.
President or other officer’s signature
Printed Name
Date
License Fee is $2,500
DEPARTMENT USE ONLY
Validation#
One copy of the completed application must be sent to all applicable municipalities
and boroughs.
Pay online with OTIS at or make check payable to State of Alaska.
Date Stamp
New applicants must pay by check.
853
Mail to: Alaska Department f Revenue, PO Box 110420, Juneau AK 99811-0420
0405-853 Rev 0
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