Fillable Form 854 - Pull-Tab Vendor Registration

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854:08 30 13

Alaska

854

2014 Pull-Tab Vendor Registration

A registration is required for each vendor location. A permittee may not contract with more than five vendors at one time.

Permittee Information

Federal EIN

Gaming permit #

Permittee Name

Phone Number

Member in Charge

Member in Charge Phone Number

Vendor Information

Beverage Dispensary License #

Package Store License #

EIN

SSN*

Owner Name

Business License

Business Name

Phone Number

Fax Number

Mailing Address

Physical Address of Vendor Location

City

State

Zip Code

City of Vendor Location

State

Zip Code

Legal Questions

*If your business has not been issued a federal EIN, you are required to provide your social security number.

These questions must be answered. If you answer Yes to any question, please submit the person’s name, date of birth, social security

number and position of responsibility.

No Has any member of management or any person who is responsible for gaming activities ever been convicted of a felony, extortion, or a

Yes

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?

Do you employ or have a contract with the primary or alternate member in charge, officer, board member or manager of gaming for the

Yes

above organization?

No Do you have a contract other than a vendor contract with the organization listed above?

Yes

Vendor Contract to Sell Pull-Tabs

Pursuant to AS 05.15.188, the vendor listed above hereby agrees to sell pull-tabs as a vendor on behalf of the permittee listed above.

The vendor further agrees that, as compensation for expenses incurred in selling pull-tabs on behalf of the permittee,

of the ideal net of

each game may be retained by the vendor as compensation. Permittee must receive at least 70% of the ideal net from each game. AS 05.188(h).

The vendor further agrees that an amount equal to the ideal net, less the compensation owed to the vendor, shall be paid by check by the vendor to the

permittee upon delivery of a pull-tab series. AS 05.15.188(i).

It is further agreed that the vendor will ensure pull-tab winners of $50 or more will complete prize receipt forms; that a prize winner summary form will

be completed for each pull-tab game and retained with those winning pull-tabs AS 05.15.187(i); and these records of pull-tab winners will be given to the

permittee to retain for the required two or three years. AS 05.15.187(f).

It is further agreed that it is the vendor’s responsibility to ensure gaming activity at this vendor location is conducted in accordance with all applicable

state statutes and regulations.

It is further agreed that, if the vendor is no longer eligible to sell pull-tabs, then all unopened and opened pull-tab games shall be returned to the permittee

within 10 days. If the permittee loses the privilege to conduct gaming activities, then all unopened and opened pull-tab games must be treated in

accordance with 15 AAC 160.490.

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.

Vendor Signature

Printed Name

Date

Member in Charge Signature

Printed Name

Date

Registration Fee is $50

DEPARTMENT USE ONLY

Validation #

Pay online using (OTIS) at or make your check payable to

the State of Alaska. This completed registration form must be attached to a

Date Stamp