Form 859 - Multiple-Beneficiary Permit Application - 2013
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Alaska
859
2013 Multiple-Beneficiary Permit Application
MBP Information
Apply online at
EIN
If renewing, MBP Permit #
Phone Number
Fax Number
MBP Name
Email
Zip Code
Mailing Address
City
State
AK
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
alternate, attach a separate sheet.
Primary Member First Name M.I.
Primary Member Last Name
Alternate Member First Name M.I.
Alternate Member Last Name
Social Security Number
Email
Social Security Number
Email
Daytime Phone Number
Mobile Number
Daytime Phone Number
Mobile Number
Home Mailing Address
Home Mailing Address
Zip Code
Zip Code
City
State
City
State
AK
AK
Has the primary member passed the test?
Permit # under which test
Permit # under which test
Has the alternate member passed the test?
was taken:
was taken:
Yes
No
Yes
No
MBP Member Applicants
All member applicants must (1) have a permit or (2) have applied for a permit for this permit year.
Permit #
Name of Organization
Phone Number
Permit #
Name of Organization
Phone Number
Permit #
Name of Organization
Phone Number
Permit #
Name of Organization
Phone Number
Permit #
Name of Organization
Phone Number
Permit #
Name of Organization
Phone Number
Legal Questions
These questions must be answered, If you answer Yes to either question, see instructions.
Yes
No Has 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?
No Does any member of management or any person who is responsible for gaming activities have a prohibited conflict of interest as defined
Yes
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
Permit Fee $100
DEPARTMENT USE ONLY
One copy of the completed application must be sent to all applicable municipalities and boroughs.
Validation #
See instructions for mandatory attachments.
Pay online with OTIS at or make check payable to State of Alaska. New applicants
Date Stamp
must pay by check.
859
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-859 Rev 04/22/13 - page 1
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