Form 859 - Multiple-Beneficiary Permit Application - 2014 Page 2
Download a blank fillable Form 859 - Multiple-Beneficiary Permit Application - 2014 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 859 - Multiple-Beneficiary Permit Application - 2014 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Alaska
859
2014 Multiple-Beneficiary Permit Application
MBP Permit #
MBP Name
Supervisory Employees
First Name
M.I.
Last Name
Social Security Number
First Name
M.I.
Last Name
Social Security Number
First Name
M.I.
Last Name
Social Security Number
Activities Conducted by MBP
Is any facility rented or leased from an MBP member?
No
Yes If Yes, see instructions
Facility Name
Facility Type (check one)
Owned
Leased
Donated
Raffles
Game Type(s)
Bingo
Pull-Tabs
Other (specify):
Physical Address
City
State
Zip Code
Facility Name
Facility Type (check one)
Owned
Leased
Donated
Raffles
Game Type(s)
Bingo
Pull-Tabs
Other (specify):
Physical Address
City
State
Zip Code
Facility Name
Facility Type (check one)
Owned
Leased
Donated
Raffles
Game Type(s)
Bingo
Pull-Tabs
Other (specify):
Physical Address
City
State
Zip Code
Vendor Information
Vendors may sell pull-tabs only. Attach vendor registration form(s) and fee(s) for each vendor listed below.
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
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
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
AK
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
AK
Manager of Games
As defined in 15 AAC 160.995 and 15 AAC 160.365
Manager First Name
M.I.
Manager Last Name
Social Security Number Daytime Phone Number
Home Mailing Address
City
State
Zip Code
Mobile Number
Permit # under which test was taken:
Has this manager passed the test?
Yes
No
859
0405-859 Rev 10/23/13 - page 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial