Form 04-859 - Multiple-Beneficiary Permit Application - 1999 Page 2
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21999 Multiple-Beneficiary Permit Application
MBP Name
Federal EIN
Permit Number
MANAGER AND SUPERVISORY EMPLOYEES
Social Security Number
Name
Manager
Supervisor
Social Security Number
Name
Manager
Supervisor
Social Security Number
Name
Manager
Supervisor
Social Security Number
Name
Manager
Supervisor
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
ACTIVITIES CONDUCTED BY MBP
Facility Name
Physical Location
Game Type
Is Facility
Owned
Leased
Donated
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
1.
2.
3.
4.
5.
Use additional sheets if necessary.
Form 04-859 (revised 10/98)back
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