Form 0405-826 - Gaming Permit Application - 2014 Page 2
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1
22014 Alaska Gaming Permit Application
826
Organization Name
Gaming Permit #
Facility-Based Games (self-directed)
If more than two facilities, attach a separate sheet.
Facility Name
Physical Address
City
State
Zip Code
AK
Facility Type (check one)
Game Type (check all that apply)
Raffle
Animal classic (chicken)*
Animal classic (rat race)*
Special draw raffle **
Bingo
Pull-tabs
Owned
Leased
Donated
Calcutta pool**
Facility Name
Physical Address
City
State
Zip Code
AK
Facility Type (check one)
Game Type (check all that apply)
Raffle
Animal classic (chicken)*
Animal classic (rat race)*
Special draw raffle **
Bingo
Pull-tabs
Owned
Leased
Donated
Calcutta pool**
Area-Based Games
If more than two areas, attach a separate sheet. * restricted game type
**see instructions for mandatory attachments
Game type (check all that apply)
Classic/
Area
Raffle
Dog musher’ contest
Other (specify) ______________
Contest of skill
Fish derby
Game type (check all that apply)
Classic/
Area
Other (specify) _________________
Raffle
Dog musher’ contest
Contest of skill
Fish derby
Manager of Games
Required only for self-directed pull-tabs and bingo.
Social Security Number
Manager First Name
MI
Manager Last Name
Daytime Phone Number
Home Mailing Address
Email
Mobile Phone
Permit # under which test taken
City
State
Zip Coded
Has the manager of games passed the test?
Yes
No
Vendor Information
Attach 2013 vendor registration form(s) and fee(s) for each vendor listed below.
Physical Address
Bar or Liquor Store Name
City
Zip Code
State
AK
Physical Address
Bar or Liquor Store Name
City
Zip Code
State
AK
Physical Address
Bar or Liquor Store Name
City
Zip Code
State
AK
Physical Address
Bar or Liquor Store Name
City
State
Zip Code
AK
Physical Address
Bar or Liquor Store Name
City
State
Zip Code
AK
Operator Information
Designate operator who will conduct activities on the organization’s behalf. Attach signed operating contract(s). If more than one operator, attach a separate sheet.
Operator License #
Facility Name
Game Type(s)
Operator
Physical Address
City
State
Zip Code
Multiple-Beneficiary Permittee Information (MBP)
Designate the MBP with which the organization has signed a partnership or joint venture agreement.
Facility Name
Game Type(s)
MBP Permit #
MBP Name
Physical Address
City
State
Zip Code
Dedication of Net Proceeds
Describe in detail how the organization will use the net proceeds from gaming activities.
826
0405-826 Rev 08/30/13 - page 2
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Parent category: Financial