Form 04-847 - 2000 Operator License Application As 05.15.122 Page 2
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1
22000 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
Form 04-847 (Rev 09/99) Back
Use additional pages as necessary.
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