Form 859a - Amended Multiple-Beneficiary Permit Application - 2014
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859A:08 30 13
Alaska
859A
2014 Amended Multiple-Beneficiary Permit Application
MBP Information
MBP Permit #
Federal EIN
MBP Name
Complete only if there is a change in address.
Mailing Address
City
State
Zip Code
AK
Phone Number
Fax Number
Webstie Address
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
change to either position, attach a separate sheet.
Primary Member First Name
M.I.
Primary Member Last Name
Email
Effective Date
Add
Delete
Social Security Number
Daytime Phone Number
Mobile Number
Has the primary member passed the test?
SELECT ONE
Home Mailing Address
City
State
Zip Code
Permit # under which test was taken:
AK
Alternate Member First Name
M.I.
Alternate Member Last Name
Email
Effective Date
Add
Delete
Social Security Number
Daytime Phone Number
Mobile Number
Has the alternate member passed the test?
SELECT ONE
Home Mailing Address
City
State
Zip Code
Permit # under which test was taken:
AK
Change in MBP Member Applicants
All member applicants must (1) have a permit or (2) have applied for a permit for this permit year. If more than two changes, attach a separate sheet.
Permit #
Name of Organization
Phone Number
Add
Delete
Permit #
Name of Organization
Phone Number
Add
Delete
Legal Questions
These questions must be answered, If you answer Yes to either question, see instructions.
Has any member of management or any person who is responsible for gaming activities ever been convicted of a felony, extortion, or a
Yes
No
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?
Does any member of management or any person who is responsible for gaming activities have a prohibited conflict of interest as defined
Yes
No
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
Alternate Member Signature
Printed Name
Date
Manager Signature
Printed Name
Date
One copy of the completed application must be sent to all applicable municipalities and boroughs.
DEPARTMENT USE ONLY
See instructions for mandatory attachments.
Date Stamp
859A
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-859A Rev 08/30/13 - page 1
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