Form 04-826 - Gaming Permit Application - 1999 Page 2
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1
21999 Gaming Permit Application
Organization Name
Federal EIN
Permit Number
Game Type (use for completing information below.)
Bingo
Deep Freeze Classics
Goose Classics
Race Classics
Raffles
Dog Musher's Contest
Ice Classics
Rain Classics
Pull-Tabs
Dog Mushing Sweepstakes
King Salmon Classics
Salmon Classics
Contest of Skills
Fish Derbies
Mercury Classics
Snow Machine Classics
Canned Salmon Classics
ACTIVITES CONDUCTED BY ORGANIZATION
Facility Name
Physical Address
Game Type
Is Facility
Owned
Leased
Donated
Owned
Leased
Donated
Owned
Leased
Donated
Owned
Leased
Donated
Owned
Leased
Donated
Owned
Leased
Donated
ACTIVITIES CONDUCTED BY VENDOR (pull-tabs are the only games a vendor can conduct) V endor registration and fee must be attached.
Name of Vendor
Physical Location
Vendor Number
ACTIVITIES CONDUCTED BY OPERATOR
Name of Operator
Physical Location
Game Type(s)
Operator's License Number
ACTIVITIES CONDUCTED BY MULTIPLE-BENEFICIARY PERMITTEE
Name of MBP
Physical Location
Game Type(s)
MBP Number
DEDICATION OF NET PROCEEDS. The organization must plan to use the net proceeds from gaming activities for political, educational, civic, public, charitable,
patriotic or religious uses in Alaska. (See statutes and regulations for specific rules.) In the space provided, tell how your organization intends to use the net
proceeds from gaming activities. (Be specific)
04-826 (revised 10/98) back
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Parent category: Financial