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Form 859a 2013 Multiple-Beneficiary Permittee Application Amended Fill In
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)Delete Yes No 2013 Amended Multiple Beneficiary Permit Application 859A859A 859A859A0405 859A Rev 04/17/13 page 1 Activities Conducted by MBP Alaska All member applicants must (1) have a permit or (2) have applied for a permit for this permit year If more than two changes attach a separate sheet Alternate Member First Name Alternate Member Last Name Alternate Member Signature Attach vendor registration form(s) and fee(s) If more than two changes attach a separate sheet Bar or Liquor Store Name Bingo by 15 AAC 160 954? Change in MBP Member Applicants Change in Vendor Change of Supervisory Employees If more than two changes attach a separate sheet change to either position attach a separate sheet Complete only if there is a change in address Date Stamp Daytime Phone Number Daytime Phone Number Delete Delete Delete Delete Delete DEPARTMENT USE ONLY Does any member of management or any person who is responsible for gaming activities have a prohibited conflict of interest as defined Donated Effective Date Effective Date Effective Date Email Email Facility Name Facility Type Fax Number Federal EIN First Name Game Type(s) Has any member of management or any person who is responsible for gaming activities ever been convicted of a felony extortion or a Has the alternate member passed the test? Has the primary member passed the test? Has this manager passed the test? Home Mailing Address Home Mailing Address Is any facility rented or leased from an MBP member? No Yes If Yes see instructions If more than two changes attach a separate sheet knowledge and belief it is true and complete We understand that any false statement made on the application or any attachments is punishable by Last Name 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 laws? Leased Legal Questions These questions must be answered If you answer Yes to either question see instructions Mail to: Alaska Department of Revenue PO Box 110420 Juneau AK 99811 0420 Mailing Address Manager First Name Manager Last Name Manager of Games As defined in 15 AAC 160 995 and 15 AAC 160 365 If more than two changes attach a separate sheet Manager Signature MBP Information MBP Name MBP Permit # 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 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 of Games Mobile Number Mobile Number Name of Organization One copy of the completed application must be sent to all applicable municipalities and boroughs Other (specify): Owned Permit # Permit # under which test was taken: Permit # under which test was taken: Phone Number Phone Number Physical Address Physical Address Primary Member First Name Primary Member Last Name Primary Member Signature Printed Name Printed Name Pull Tabs Raffles Revenue to review any criminal history we may have in accordance with 15 AAC 160 934 See instructions for mandatory attachments Social Security Number Social Security Number Social Security Number State State State State State violation of law or ordinance of this state or another jurisdiction that is a crime involving theft or dishonesty or a violation of gambling We declare under penalty of unsworn falsification that we have examined this application including any attachments and that to the best of our Zip Code Zip Code Zip Code Zip Code Zip Code