Instructions For 2013 Alaska Operator License Application Check List
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1Instructions for 2013 Alaska Operator License
Application Check List
Failure to complete any portion of this application
Mandatory Attachments:
will result in the delay of your operator license being
Proof of insurance [AS 05.15.122(b)(4), 15 AAC 160.210].
issued.
Use these instructions to make sure all
information has been completed and is attached.
Bond or security [AS 05.15.122(b)(5), AS 05.15.167, 15 AAC
160.200].
Copy of lease agreement.
Page 1: Operator License Application
Enter your federal employer identification number (EIN), operator
Copy of signed operator contract for each permittee.
license number if applicable, and check a box to indicate “type of
operator.” If you are a permittee or municipality, also enter your
permit number.
Complete all other boxes under Operator Information. If you are
Reminder
a permittee or municipality enter the name of the permittee or
Addenda to contracts must be submitted to and approved by the
municipality in the business name box.
department before the contract can become effective.
LOCATION(S) OF ACTIVITY
Operator’s License Application
Enter the facility name, physical address, city, phone number,
Regulations 15 AAC 160.030(e). An applicant for an operator’s license
and the types of games that will be licensed at the facility. Attach
that is not a municipality shall accomplish the notice required under
separate sheets as necessary.
AS 05.15.030(a) by submitting one copy of the application described
under AS 05.15.122(b) to the city or borough nearest to each location
in which the applicant seeks to conduct an activity permitted under AS
LEGAL QUESTIONS
05.15.
Answer the questions by checking the appropriate box. If you
check “yes” to either question, you must submit, as an attachment,
the person’s name, date of birth, social security number, and
Mail Form 847 To:
position of responsibility.
TAX DIVISION - GAMING GROUP
ALASKA DEPARTMENT OF REVENUE
PO BOX 110420
JUNEAU AK 99811-0420
SIGNATURES & PAYMENT
If the operator is an individual, then that individual must sign and
date the application, and print his or her name. If the operator is
a permittee or municipality, the primary member in charge must
sign and date the application and print his or her name. The $500
application fee may be paid online at , or
you can submit a check payable to the State of Alaska with your
application. Payment must be received before your application will
be processed.
Page 2: Operator License Application
Enter your name and operator license number at the top of page 2.
CONTRACTED PERMITTEES
Enter the permit number, name of the organization and type
of games to be played for each permittee for whom you will
be conducting gaming activities.
Attach additional sheets as
necessary.
MANAGERS AND SUPERVISORS
You must disclose the identity of each person employed in a
managerial or supervisory capacity. AS 05.15.122(3). Enter all
requested information for each manager and supervisor. Attach
additional sheets as necessary.
0405-847i - Rev 08/12 - page 1
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