Form 0405-826a - Amended Gaming Permit Application - 2014
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Alaska
826A:10 22 13
826A
2014 Amended Gaming Permit Application
With the exception of the EIN, gaming permit number, and the organization name, complete only the information that has changed from information
submitted on the original application for this permit year.
Organization Information
EIN
Gaming permit #
Phone Number
Fax Number
Organization Name
Website Address
City
Zip Code
Mailing Address
State
AK
Entity Type (check one)
Organization Type (check one) for definitions see AS 05.15.690 and 15 AAC 160.995.
Corporation
Charitable
Police or fire department
Fraternal
Civic or service
Partnership
Labor
Political
Dog mushers’ association
Association
Municipality
Religious
Nonprofit trade association
Educational
Veterans
IRA/Native Village
Fishing derby association
Outboard motor association
Yes
No Does the organization have 25 or more members who are Alaska residents as defined in your articles of incorporation or bylaws?
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.
Alternate Member First Name M.I.
Primary Member Last Name
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
Zip Code
City
Zip Code
State
State
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
Effective Date of change
Effective date of change
Add
Delete
Add
Delete
Legal Questions
These questions must be answered, If you answer Yes to either question, see instructions.
Yes
No Has any member of management or any person who is responsible for gaming activities ever been convicted of a felony,
extortion, or a violation of law or ordinance of this state, or another jurisdiction, that is a crime involving theft or dishonesty,
or a violation of gambling laws?
No Does any member of management or any person who is responsible for gaming activities have a prohibited conflict of
Yes
interest as defined by 15 AAC 160.954.
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 Signature
Printed Name
Date
President or Other Officer’s Signature (see instructions)
Printed Name
Date
Alternate Member Signature
Printed Name
Date
Manager Signature
Printed Name
Date
DEPARTMENT USE ONLY
Date Stamp
One copy of the completed application must be sent to the nearest municipality and
borough. See instructions for mandatory attachments.
826A
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-826A Rev 10/22/13 - page 1
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