Form 0405-826a - Amended Gaming Permit Application - 2014 Page 2
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1
2Alaska
826A
2014 Amended Gaming Permit Application
Gaming Permit #
Organization Name
Facility-Based Games (self-directed)
If more than two facilities, attach a separate sheet.
City
Zip Code
Facility Name
Physical Address
State
Add
AK
Delete
Facility Type (check one)
Game Type
Raffle
Animal classic (chicken)*
Bingo
Pull-tabs
(check all that apply)
Owned
Leased
Donated
Animal classic (rat race)*
Special draw raffle **
Calcutta pool**
City
Zip Code
Facility Name
Physical Address
State
Add
AK
Delete
Facility Type (check one)
Raffle
Animal classic (chicken)*
Game Type
Bingo
Pull-tabs
(check all that apply)
Owned
Leased
Donated
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)
Dog musher’ contest
Classic/Other (specify) ___________________
Delete
Area
Game type
Raffle
Contest of skill
Fish derby
Add
(check all that apply)
Dog musher’ contest
Classic/Other (specify) ___________________
Delete
Manager of Games
Required only for self-directed pull-tabs and bingo.
MI
Manager First Name
Manager Last Name
Social Security Number
Daytime Phone Number
Add
Delete
City
Home Mailing Address
State
Zip
Effective Date of Change
Email
Has the manager of games passed
Permit # under which
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.
City
Zip Code
Bar or Liquor Store Name
Physical Address
State
Add
AK
Delete
City
Zip Code
Bar or Liquor Store Name
Physical Address
State
Add
AK
Delete
City
Zip Code
Bar or Liquor Store Name
Physical Address
State
Add
AK
Delete
City
Zip Code
Bar or Liquor Store Name
Physical Address
State
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.
Game Type(s)
Operator License #
Operator
Facility Name
Add
Delete
City
Zip Code
Physical Address
State
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.
Game Type(s)
MBP Permit #
MBP Name
Facility Name
Add
Delete
City
Zip Code
Physical Address
State
Dedication of Net Proceeds
Describe in detail how the organization’s use of net proceeds from gaming activities will change.
826A
0405-826A Rev 10/22/13 - page 2
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