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Form Lic/gam 5471 - List Of Elected Executive - Alberta Gaming And Liquor Commission

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LIST OF ELECTED EXECUTIVE

It is imperative that the Alberta Gaming and Liquor Commission (AGLC) be kept informed of any changes to

the elected executive. Please provide information for all bona fide executive members and positions

authorized to sign documents forwarded to AGLC. Complete this form and return to the AGLC as follows:

Alberta Gaming and Liquor Commission

Regulatory Division, 50 Corriveau Avenue, St. Albert, Alberta T8N 3T5

Fax (780) 447-8911 or (780) 447-8912, email: gaming.licensing@aglc.gov.ab.ca

Group Name and Mailing Address:

AGLC ID Number:

Date Completed:

Email:

Website:

RESIDENT

Term Expiry Date:

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

(

)

(

)

(

)

REASURER

Term Expiry Date:

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

(

)

(

)

(

)

ECRETARY

Term Expiry Date:

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

(

)

(

)

(

)

ICE

RESIDENT

Term Expiry Date:

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

(

)

(

)

(

)

CONTINUED ON BACK

FORM LIC/GAM 5471 (05/07)

Form Lic/gam 5471 - List Of Elected Executive - Alberta Gaming And Liquor Commission

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