Form 04-169 - Coin-Operated Equipment Distributor'S Permit Application Page 2
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1
2MUST BE NOTARIZED
DISTRIBUTOR’S AFFIDAVIT
Individual’s Name
Subscribed and sworn to at _______________________________________
Social Security No. (Optional)
Title or Position
_______________________________________________________________
Convicted of a felony (check one)
U.S. Citizen
YES
NO
YES
NO
this ______________________ day of _______________________________
Length of Alaskan Residency (must be one year or more)
Notary Public for ________________________________________________
Individual’s Signature
My Commission expires __________________________________________
MUST BE NOTARIZED
DISTRIBUTOR’S AFFIDAVIT
Individual’s Name
Subscribed and sworn to at _______________________________________
Social Security No. (Optional)
Title or Position
_______________________________________________________________
Convicted of a felony (check one)
U.S. Citizen
YES
NO
YES
NO
this ______________________ day of _______________________________
Length of Alaskan Residency (must be one year or more)
Notary Public for ________________________________________________
Individual’s Signature
My Commission expires __________________________________________
MUST BE NOTARIZED
DISTRIBUTOR’S AFFIDAVIT
Individual’s Name
Subscribed and sworn to at _______________________________________
Social Security No. (Optional)
Title or Position
_______________________________________________________________
Convicted of a felony (check one)
U.S. Citizen
YES
NO
YES
NO
this ______________________ day of _______________________________
Length of Alaskan Residency (must be one year or more)
Notary Public for ________________________________________________
Individual’s Signature
My Commission expires __________________________________________
MUST BE NOTARIZED
DISTRIBUTOR’S AFFIDAVIT
Individual’s Name
Subscribed and sworn to at _______________________________________
Social Security No. (Optional)
Title or Position
_______________________________________________________________
Convicted of a felony (check one)
U.S. Citizen
YES
NO
YES
NO
this ______________________ day of _______________________________
Length of Alaskan Residency (must be one year or more)
Notary Public for ________________________________________________
Individual’s Signature
My Commission expires __________________________________________
MUST BE NOTARIZED
DISTRIBUTOR’S AFFIDAVIT
Individual’s Name
Subscribed and sworn to at _______________________________________
Social Security No. (Optional)
Title or Position
_______________________________________________________________
Convicted of a felony (check one)
U.S. Citizen
YES
NO
YES
NO
this ______________________ day of _______________________________
Length of Alaskan Residency (must be one year or more)
Notary Public for ________________________________________________
Individual’s Signature
My Commission expires __________________________________________
Form 04-169 Back (Rev. 12/95)
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