Form 0405-826 - Gaming Permit Application - 2013
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DEPARTMENT USE ONLY
Validation #
Alaska
826
Date Stamp
2013 Gaming Permit Application
Organization Information
Federal EIN
If renewing, enter gaming permit #
Phone Number
Fax Number
Organization Name
Website Address
Mailing Address
City
State
Zip Code
AK
Entity Type
Organization Type
(check one)
(check one) for definitions see AS 05.15.690 and 15 AAC 160.995.
Corporation
Charitable
Fraternal
Police or fire department
Partnership
Civic or service
Labor
Political
Association
Dog mushers’ association
Municipality
Religious
Educational
Nonprofit trade association
Veterans
Fishing derby association
Outboard motor association
IRA/Native Village
Yes
No Does the organization have 25 or more members, as defined in your articles of incorporation or bylaws, who are Alaska residents?
Members in Charge of Games
Members in charge must be natural persons and active members of the organization or employees of the municipality and designated by the organization.
Members in charge may not be licensed as an operator, be a registered pull-tab vendor or an employee of a vendor for this organization. If more than one
alternate, attach a separate sheet.
Primary Member First Name M.I.
Primary Member Last Name
Alternate Member First Name M.I.
Alternate Member Last Name
Social Security Number
Email
Social Security Number
Email
Daytime Phone Number
Mobile Number
Daytime Phone Number
Mobile Number
Home Mailing Address
Home Mailing Address
City
State
Zip Code
City
State
Zip Code
AK
AK
Has the primary member passed the test?
Permit # under which test
Permit # under which test
Has the alternate member passed the test?
was taken:
was taken:
Yes
No
Yes
No
Legal Questions
These questions must be answered, If you answer Yes to either question, see instructions.
Does any member of management or any person who
Has any member of management or any person who is
Yes
No
Yes
No
is responsible for gaming activities have a prohibited
responsible for gaming activities ever been convicted of
conflict of interest as defined by 15 AAC 160.954?
a felony, extortion, or a violation of a law or ordinance of
this state, or another jurisdiction, that is a crime involving
theft or dishonesty, or a violation of gambling laws?
We declare, under penalty of unsworn falsification, that we have examined this application, including any attachments, and that, to the best
of our knowledge and belief, it is true and complete. We understand that any false statement made on the application or any attachments is
punishable by law. By our signatures below we, the primary member, the alternate member, and if applicable, the manager of games, agree to
allow the Department of Revenue to review any criminal history we may have, in accordance with 15 AAC 160.934.
Primary Member In Charge’s Signature
Printed Name
Date
President or Other Officer’s Signature (see instructions)
Printed Name
Date
Alternate Member In Charge’s Signature
Printed Name
Date
Manager of Games Signature
Printed Name
Date
Permit Fee
One copy of the completed application must
The permit fee is based on the 2012 estimated
be sent to the nearest municipality or borough.
gross receipts. Check the appropriate box.
See instructions for mandatory attachments.
New applicant
$20
Pay online with OTIS at or make check
$0 - $20,000
$20
payable to State of Alaska. New applicants must pay by
check.
$20,001 - $100,000
$50
$100,001 or more
$100
826
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-826 Rev 04/15/13 - page 1
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