Fillable Form 859 - Multiple-Beneficiary Permit Application

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859:10 23 13

Alaska

859

2014 Multiple-Beneficiary Permit Application

MBP Information

Apply online at

EIN

If renewing, MBP Permit #

Phone Number

Fax Number

MBP Name

Website Address

Mailing Address

City

State

Zip Code

Members in Charge of Games

Members in charge must be natural persons and active members of the organization or employees of the municipality and designated by the organization.

Members in charge may not be licensed as an operator, be a registered pull-tab vendor or an employee of a vendor for this organization. If more than one

alternate, attach a separate sheet.

Primary Member First Name M.I.

Primary Member Last Name

Alternate Member First Name M.I.

Alternate Member Last Name

Social Security Number

Daytime Phone Number

Mobile Number

Daytime Phone Number

Mobile Number

Home Mailing Address

City

State

Zip Code

City

State

Zip Code

Has the primary member passed the test?

Permit # under which test

Has the alternate member passed the test?

was taken:

Yes

MBP Member Applicants

All member applicants must (1) have a permit or (2) have applied for a permit for this permit year.

Permit #

Name of Organization

Phone Number

Permit #

Name of Organization

Phone Number

Permit #

Name of Organization

Phone Number

Permit #

Name of Organization

Phone Number

Permit #

Name of Organization

Phone Number

Permit #

Name of Organization

Phone Number

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?

No Does any member of management or any person who is responsible for gaming activities have a prohibited conflict of interest as defined

Yes

by 15 AAC 160.954?

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

is true and complete. We understand that any false statement made on the application or any attachments is punishable by law. By our signatures below we, the primary

member, the alternate member, and if applicable, the manager of games, agree to allow the Department of Revenue to review any criminal history we may have, in accordance

with 15 AAC 160.934.

Primary Member Signature

Printed Name

Date

Alternate Member Signature

Printed Name

Date

Manager Signature

Printed Name

Date

Permit Fee $100

DEPARTMENT USE ONLY