Instructions For 2013 Alaska Amended Operator License Application printable pdf download

Instructions for 2013 Alaska Amended

Operator License Application

LOCAL MUNICIPALITY

Use the amended operator application to correct errors or make

changes to information submitted on your original 2013 operator

A change of location(s) for permittees requires notice under AS

license application. Please allow three to four weeks for the

05.15.030(a). You can accomplish this notice requirement by

amended application to be processed.

submitting one copy of your amended application to the city or

borough nearest to the location where activity will be conducted

Note: If you add a game type or change gaming locations, you

under AS 05.15.

must submit a copy of the completed amended application to the

nearest municipality or borough where the gaming activities will

Mail Form 847A to

occur.

TAX DIVISION - GAMING GROUP

ALASKA DEPARTMENT OF REVENUE

OPERATOR INFORMATION

PO BOX 110420

List your federal employer identification number (EIN) or social

JUNEAU AK 99811-0420

security number and your legal name. Do not complete any of the

other information requested in this section unless the information

reported on your original application has changed

CHANGE OF LOCATION(S) OF ACTIVITY

If you are adding a facility, check the add box and complete all

information requested in this section for the new facility. Attach a

copy of the lease (if applicable), verification of liability insurance

and amended contracts for each permittee for whom games will

be conducted at the new location.

If you have ceased gaming activity at a facility where you have

previously been licensed, check the delete box and enter the

name and physical address of the facility.

Additionally, the permittee must complete and submit an

application or amended application along with the contract or

amended contract for the new location or activity.

CHANGE IN CONTRACTED PERMITTEE

If you are adding a permittee, enter the permittee’s permit

number, name and the type of games that will be conducted on

the permittee’s behalf and submit a copy of the contract with the

permittee.

If you are deleting a permittee, check the delete box, enter

the permittee’s permit number, name, and the type of games

previously conducted on the permittee’s behalf.

MANAGERS & SUPERVISORS

Add a manager or supervisor by checking the add box and by

completing all information requested under this section.

Delete a manager or supervisor by checking the delete box and

entering the employee’s first name, middle initial, last name and

social security number. Attach additional sheets as necessary.

LEGAL QUESTIONS

Answer the questions by checking the yes or no box. If you answer

yes to either question, you must submit the person’s name, date

of birth, social security number and position of responsibility.

SIGNATURE

The operator must sign and date the amended application.

0405-847Ai Rev 09/12

Instructions For 2013 Alaska Amended Operator License Application

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