Form 04-071o - 2005 Amended Operator License Application
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1State of Alaska
Department of Revenue
2005 Amended Operator
Tax Division, Gaming Group
License Application
PO Box 110420
AS 05.15.020
Juneau, AK 99811-0420
Telephone 907.465.2320
Date Stamp
This form is also available on the Internet at
OPERATOR INFORMATION
FOR OFFICIAL STATE USE ONLY
Federal EIN
Operator License Number
Telephone Number
Fax Number
Operator's First Name
Operator's Last Name
E-mail Address
COMPLETE ONLY IF THERE IS A CHANGE IN ADDRESS
Mailing Address
City
State
Zip Code
GAME TYPE (use for completing information below)
Bingo
Deep Freeze Classic
King Salmon Classics
Snow Machine Classics
Raffles
Dog Musher's Contest
Mercury Classics
Special Draw Raffle
Pull-Tabs
Fish Derbies
Race Classics
Animal Classic (Rat Race)
Contest of Skill
Goose Classics
Rain Classics
Animal Classic (Chicken)
Canned Salmon Classic
Ice Classics
Salmon Classics
ADDITIONAL LOCATION/ACTIVITY CONDUCTED BY OPERATOR
Facility Name
Physical Address
Game Type
Is Facility
Owned
Leased
Donated
Owned
Leased
Donated
Owned
Leased
Donated
CHANGE OF CONTRACTED PERMITTEE
Name of Permittee
Mailing Address
Game Type(s)
Permit Number
Add
Delete
Add
Delete
THESE QUESTIONS MUST BE ANSWERED. (If you answer yes to either question, please submit the persons name and position of responsibility.)
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 a 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?
I declare under penalty of unsworn falsification, that I have examined this application, including any attachment, and that to the best of my knowledge and belief,
it is true and complete. I understand that any false statement made on this application or any attachments is punishable by law.
Operator Signature
Printed Name
Date
X
All sections must be completed. See Instructions for mandatory attachments.
Two copies of this application must be sent to all applicable municipalities and boroughs.
Form 04-071O (Rev. 09/04)
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