Form 04-847 - Operator License Application - 1999 Page 2
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21999 Operator License Application
Operator Name
Federal EIN
License Number
CONTRACTED PERMITTEES (list permittees for whom you will conduct gaming activities.)
Permit Number
Name of Organization
Location
Game Type(s)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
EMPLOYEES (Please provide the required information for each person who manages or supervises any of the licensed gaming activities as defined in AS 05.15.122.)
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
1
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
2
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
3
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
4
City, State, Zip Code
Position Title
Employee Name
Social Security Number
Mailing Address
Home Telephone Number
5
City, State, Zip Code
Position Title
Use additional pages as necessary.
Form 04-847 back (revised10/98)
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Parent category: Financial