Form 04-847 - Operator License Applicaiton - 2002 printable pdf download

Form 04-847 - Operator License Applicaiton - 2002

State of Alaska

2002 Operator License Application

Instructions

This guide is to help you successfully complete the license application and speed up the processing

time. A license will not be issued until all of the following have been completed. Please allow 3 to

4 weeks for your application to be processed.

Mandatory Attachments

proof of insurance (AS 05.15.122(b)(4), 15 AAC 160.210)

bond or security (AS 05.15.122(b)(5), AS 05.15.167, 15 AAC 160.200)

copy of lease agreement (15 AAC 160.935(e)

copy of signed contract for each permittee

Organization Information

List your federal employer identification number (EIN) or social security number (SSN). If your EIN or

SSN is missing, your license application will be delayed. List the legal name of the organization and

the mailing address.

Location of Activities

Please give a specific street address where gaming activity will be conducted by the operator.

Questions

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

If the operator is an individual, then that individual must sign the application. If the operator is a

municipality or a qualified organization, then the primary member in charge must sign the application.

License Fee

Attach the payment for $500 to the application. A license will not be issued without payment.

Contracted Permittees

For each permittee for whom you will be conducting gaming activity, list the permit number, name of

the organization, and the type of games to be played.

Employees

You must disclose the identity of each person employed in a managerial or supervisory capacity.

AS 05.15.122(3)

Reminder

Addenda to contracts must be submitted to and approved by the department before the contract

can become effective.

All sections must be completed.

Form 04-847 Instructions (Rev 08/01)

Form 04-847 - Operator License Applicaiton - 2002