Form 0405-847 - Operator License Application - 2013
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Alaska
847
2013 Operator License Application
Operator Information
If renewing, license #
Operator is:
Municipality (permit #
)
EIN
SSN
Individual
Permittee
(permit #
)
Operator First Name
M.I.
Operator Last Name
AK Business License #
Business Name
Contact Person
Mailing Address
Contact Person Phone Number
City
State
Zip Code
Contact Person Mobile Number
Daytime Phone Number
Fax Number
Mobile Number
Contact Person Email
Location(s) of Activity
You must provide proof of liability insurance for each location. If more than eight locations, attach separate sheet.
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Facility Name
Physical Address
City
Zip Code
Game Type(s)
Legal Questions
These questions must be answered, If you answer Yes to either question, see instructions.
Yes
No
Have you (the operator) or 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?
Yes
No
Do you (the operator) or any member of management or any person who is responsible for gaming activities, have a prohibited
conflict of interest as defined by 15 AAC 160.954?
I declare, under penalty of unsworn falsification, that I have examined this application, including any attachments, and that, to the best of my
knowledge and belief, it is true and complete. I understand that any false statement made on the application or any attachments is punishable by law.
With my signature below I agree to allow the Department of Revenue to review any criminal history I may have in accordance with 15 AAC 160.934.
Operator Signature
Printed Name
Date
License Fee is $500
DEPARTMENT USE ONLY
One copy of the completed application must be sent to all applicable municipalities and
Validation #
.
boroughs
See instructions for mandatory attachments.
Pay online with OTIS at or make check payable to State of Alaska.
New applicants must pay by check.
Date Stamp
847
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-847 Rev 04/17/13 - page 1
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Parent category: Financial