Alaska
859
2013 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):
Zip Code
Physical Address
City
State
Facility Name
Facility Type (check one)
Owned
Leased
Donated
Raffles
Game Type(s)
Bingo
Pull-Tabs
Other (specify):
Zip Code
Physical Address
City
State
Facility Name
Facility Type (check one)
Owned
Leased
Donated
Raffles
Game Type(s)
Bingo
Pull-Tabs
Other (specify):
Zip Code
Physical Address
City
State
Vendor Information
Vendors may sell pull-tabs only. Attach vendor registration form(s) and fee(s) for each vendor listed below.
Zip Code
Bar or Liquor Store Name
Physical Address
City
State
AK
Zip Code
Bar or Liquor Store Name
Physical Address
City
State
AK
Zip Code
Bar or Liquor Store Name
Physical Address
City
State
AK
Zip Code
Bar or Liquor Store Name
Physical Address
City
State
AK
Zip Code
Bar or Liquor Store Name
Physical Address
City
State
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
Zip Code
Home Mailing Address
City
State
Mobile Number
Permit # under which test was taken:
Has this manager passed the test?
Yes
No
859
0405-859 Rev 08/12 - page 2