Form 04-847 - Operator License Application - 2001 Page 2
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1
2Operator Name
Federal EIN
License Number
CONTRACTED PERMITTEES (list permittees for whom you will conduct gaming activities.)
Permit Number
Name of Organization
Location
Game Type(s)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
EMPLOYEES (Please provide the required information for each person who manages or supervises any of the licensed gaming activities as defined in AS 05.15.122.)
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
1
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
2
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
3
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
4
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
5
City, State, Zip Code
Position Title
Form 04-847 (Rev 08/00) Back
Use additional pages as necessary.
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Parent category: Financial