Form 0405-826 - Amended Gaming Permit Application - 2013 Page 2
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2Alaska
826A
2013 Amended 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
Add
AK
Delete
Facility Type (check one)
Game Type
Bingo
Raffle
Pull-tabs
Animal classic (chicken)*
Owned
Leased
Donated
(check all that apply)
Animal classic (rat race)*
Special draw raffle **
Calcutta pool**
Facility Name
Physical Address
City
State
Zip Code
Add
AK
Delete
Facility Type (check one)
Game Type
Bingo
Raffle
Pull-tabs
Animal classic (chicken)*
Owned
Leased
Donated
(check all that apply)
Animal classic (rat race)*
Special draw raffle **
Calcutta pool**
Area-Based Games
If more than two areas, attach a separate sheet. *restricted game type
**see instructions for manditory attachments
Area
Game type
Raffle
Contest of skill
Fish derby
Add
(check all that apply)
Delete
Dog musher’ contest
Other (specify) __________________________
Area
Game type
Raffle
Contest of skill
Fish derby
Add
(check all that apply)
Delete
Dog musher’ contest
Other (specify) __________________________
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
Add
Delete
Home Mailing Address
City
State
Zip
Email
Has the manager of games passed
Permit # under which
Effective Date of Change
the test?
test was taken
Yes
No
Change of Vendor
Vendors may only sell pull-tabs. Attach vendor registration form(s) and fee(s) for each vendor listed.
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
Add
AK
Delete
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
Add
AK
Delete
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
Add
AK
Delete
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
Add
AK
Delete
Change of Operator
Designate operator.
If adding an operator, attach a signed operating contract. If more than one change, attach a separate
sheet.
Operator License #
Operator
Facility Name
Game Type(s)
Add
Delete
Physical Address
City
State
Zip Code
Change of Multiple-Beneficiary Permittee (MBP).
Designate the MBP. If adding an MBP, attach a copy of the signed agreement. If
more than one change, attach a separate sheet.
MBP Permit #
MBP Name
Facility Name
Game Type(s)
Add
Delete
Physical Address
City
State
Zip Code
Dedication of Net Proceeds
Describe in detail how the organization’s use of net proceeds from gaming activities will change.
826A
0405-826A Rev 04/16/13 - page 2
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