Instructions Check List For 2014 - Alaska Multiple-Beneficiary Permittee Application
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1Instructions Check List for 2014
Alaska Multiple-Beneficiary Permittee Application
Failure to complete any portion of the MBP application
SUPERVISORY EMPLOYEES
or to submit mandatory attachments will delay the
Enter each supervisor’s first name, middle initial, last name, and
issuance of your MBP permit. Use this checklist to
social security number. Attach additional sheets as necessary.
make sure all information has been completed and
attached.
ACTIVITIES CONDUCTED BY MBP
Page 1: Multiple-Beneficiary Permittee Application
Is any facility rented or leased from an MBP member? Check the
yes or no box. If you answered yes, refer to 15 AAC 160.954(c)(3).
MBP INFORMATION
Complete all requested information for each facility listed under this
Enter the MBP’s Federal Employer Identification Number (EIN),
section. Attach additional sheets as necessary.
MBP permit number if applicable, phone number, and fax number.
Enter the MBP name and website address.
VENDOR INFORMATION
Enter the MBP mailing address, city, and zip code.
Enter the name of each bar or liquor store, its physical address,
city, and zip code. Attach additional sheets as necessary.
Vendor compensation may not exceed 30% of the ideal net from
MEMBERS IN CHARGE OF GAMES
each pull-tab game.
Complete all requested information for the primary member in
charge. Then complete all requested information for the alternate
member in charge. Social security numbers are required for each
MANAGER OF GAMING
member in charge. If appointing more than one alternate member
Enter the manager’s first name, middle initial, last name, social
in charge, attach additional sheets as necessary.
security number, and daytime phone number.
Enter the manager’s home mailing address, city, state zip code,
and mobile phone number.
MBP MEMBER APPLICANTS
All member applicants must have a 2014 permit before the MBP
permits will be issued.
Mandatory Attachments:
Enter each member applicant’s permit number (if applicable),
Answer sheet for each member in charge who has not previously
name, and telephone number.
passed the permittee test.
Test answer sheet for each manager who has not previously
passed the permittee test.
LEGAL QUESTIONS
Answer the questions by checking the appropriate box. If you
Lease agreement for each facility where games are conducted.
check “yes” to either question, you must submit, as an attachment,
A biennial rent appraisal for each applicable lease agreement.
the person’s name, date of birth, social security number, and
Refer to 15 AAC 160.954(c)(3).
position of responsibility.
Copy of joint venture or partnership agreement among the members,
including the percentage of participation in gross receipts for each
SIGNATURES & PAYMENT
member.
The primary member in charge should sign the application, print his
Copy of manager contracts (if applicable).
or her name, and then date the application.
A completed 2014 Pull-Tab Vendor registration form, including the
Additional signatures are required by your alternate member
percentage amount of compensation to be retained by the vendor,
in charge and your manager of games to comply with the
signed by both parties.
provisions of 15 AAC 160.934, criminal history checks.
Signature lines are provided for all required signatures at the bottom
$50 registration fee must be enclosed for each vendor registration,
of page one of the 2014 application and amended application
unless you are paying online.
forms. The 2014 application forms must contain all required
signatures before 2014 permits can be issued.
$100 MBP permit fee must be enclosed unless you are paying
online.
The $100 application fee may be paid online at
gov or you can submit a check payable to the State of Alaska with
Mail To:
your application.
TAX DIVISION - GAMING GROUP
ALASKA DEPARTMENT OF REVENUE
PO BOX 110420
Page 2: Multiple-Beneficiary Permittee Application
JUNEAU AK 99811-0420
Enter the MBP name and MBP permit number.
An applicant for a permit shall accomplish the notice required
under AS 05.15.030(a) by submitting one copy of the application to
each city or borough nearest to the location in which the applicant
seeks to conduct an activity permitted under AS 05.15.
0405-859i - Rev 08/30/13 - Page 1
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