Form 0405-826 - Gaming Permit Application - 2013 Page 2
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2013 Alaska Gaming Permit Application
Gaming Permit #
Organization Name
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)
Bingo
Raffle
Pull-tabs
Animal classic (chicken)*
Animal classic (rat race)*
Special draw raffle **
Owned
Leased
Donated
Calcutta pool**
Facility Name
Physical Address
City
State
Zip Code
AK
Facility Type (check one)
Game Type (check all that apply)
Bingo
Raffle
Pull-tabs
Animal classic (chicken)*
Animal classic (rat race)*
Special draw raffle **
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
Area
Game type (check all that apply)
Classic/
Raffle
Contest of skill
Fish derby
Dog musher’ contest
Other (specify) ______________
Area
Game type (check all that apply)
Classic/
Other (specify) _________________
Raffle
Contest of skill
Fish derby
Dog musher’ contest
Manager of Games
Required only for self-directed pull-tabs and bingo.
Manager First Name
MI
Manager Last Name
Social Security Number
Daytime Phone Number
Home Mailing Address
Email
Mobile Phone
City
State
Zip Coded
Has the manager of games passed the test?
Permit # under which test taken
Yes
No
Vendor Information
Attach 2012 vendor registration form(s) and fee(s) for each vendor listed below.
Bar or Liquor Store Name
Physical Address
City
Zip Code
State
AK
Bar or Liquor Store Name
Physical Address
City
Zip Code
State
AK
Bar or Liquor Store Name
Physical Address
City
Zip Code
State
AK
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
AK
Bar or Liquor Store Name
Physical Address
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 #
Operator
Facility Name
Game Type(s)
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.
MBP Permit #
MBP Name
Facility Name
Game Type(s)
Physical Address
City
State
Zip Code
Dedication of Net Proceeds
Describe in detail how the organization will use the net proceeds from gaming activities.
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0405-826 Rev 04/15/13 - page 2
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Parent category: Financial