Form 859a - Amended Multiple-Beneficiary Permit Application - 2014 Page 2
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2Alaska
859A
2014 Amended Multiple-Beneficiary Permit Application
MBP Permit #
MBP Name
Manager of Games
As defined in 15 AAC 160.995 and 15 AAC 160.365. If more than two changes, attach a separate sheet.
Manager First Name
M.I.
Manager Last Name
Social Security Number Daytime Phone Number
Add
Delete
Home Mailing Address
City
State
Zip Code
Mobile Number
Permit # under which test was taken:
Effective Date
Has this manager passed the test?
Yes
No
Manager First Name
M.I.
Manager Last Name
Social Security Number Daytime Phone Number
Add
Delete
Home Mailing Address
City
State
Zip Code
Mobile Number
Permit # under which test was taken:
Effective Date
Has this manager passed the test?
Yes
No
Change of Supervisory Employees.
If more than two changes, attach a separate sheet.
First Name
M.I.
Last Name
Social Security Number
Effective Date
Add
Delete
First Name
M.I.
Last Name
Social Security Number
Effective Date
Add
Delete
Activities Conducted by MBP
Is any facility rented or leased from an MBP member?
No
Yes If Yes, see instructions. If more than two changes, attach a separate sheet.
Facility Name
Facility Type
Add
Owned
Leased
Donated
Delete
Game Type(s)
Raffles
Bingo
Pull-Tabs
Other (specify):
Physical Address
City
State
Zip Code
Facility Name
Facility Type
Add
Owned
Leased
Donated
Delete
Game Type(s)
Raffles
Bingo
Pull-Tabs
Other (specify):
Physical Address
City
State
Zip Code
Change in Vendor
Attach vendor registration form(s) and fee(s). If more than two changes, attach a separate sheet.
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
Add
AK
Delete
Bar or Liquor Store Name
Physical Address
City
State
Zip Code
Add
AK
Delete
859A
0405-859A Rev 08/30/13 - page 2
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Parent category: Financial