Form Crr-0200 - Tobacco License Renewal Application - Departament Of Revenue, State Of Georgia
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1CRR-0200
(Rev 5/06)
GEORGIA DEPARTMENT OF REVENUE
TOBACCO LICENSE
P.O. BOX 49728
RENEWAL APPLICATION
ATLANTA, GA 30359
RENEWAL FOR YEAR
Print
Clear
STATE TAXPAYER IDENTIFIER
TOTAL FEE
LICENSE NUMBER
DBA (IF DIFFERENT THAN LEGAL BUSINESS NAME)
LOCATION ADDRESS (LINE 1)
LOCATION ADDRESS (LINE 2)
CITY
STATE
ZIP CODE
AREA CODE
TELEPHONE
COUNTY
OWNERSHIP TYPE
FEI NUMBER
GA WITHHOLDING
SALES & USE TAX NUMBER
NUMBER
RELATIONSHIP SECTION
TYPE
NAME
HOME/LOCATION ADDRESS
SOCIAL SECURITY NUMBER
TOBACCO LICENSE SECTION
LICENSE TYPE
WHAT WERE YOUR GROSS SALES OF TAXABLE CIGARS, CIGARETTES, SMOKELESS TOBACCO AND
LOOSE TOBACCO FOR THE PREVIOUS LICENSE YEAR?
SIGNATURE SECTION
NOTE: BEFORE SIGNING THIS APPLICATION, CHECK ALL ANSWERS AND EXPLANATIONS TO SEE THAT ALL QUESTIONS ARE ANSWERED FULLY
AND CORRECTLY. THIS APPLICATION IS TO BE EXECUTED UNDER OATH AND SUBJECT TO THE PENALTIES OF FALSE SWEARING
AND IT INCLUDES ALL ATTACHED SHEETS SUBMITTED HEREWITH. APPLICANT UNDERSTANDS THAT ANY LICENSE ISSUED PURSUANT
TO THIS APPLICATION IS CONDITIONED UPON THE TRUTH OF THE ANSWERS AND STATEMENTS MADE HEREIN AND THAT ANY FALSE
ANSWERS AND STATEMENTS HEREIN SHALL CONSTITUTE CAUSE FOR THE SUSPENSION OR REVOCATION OF ANY LICENSE ISSUED
PURSUANT TO THIS APPLICATION. SHOULD ANY CHANGE OCCUR DURING THE YEAR FOR WHICH A LICENSE IS ISSUED PURSUANT
TO THIS APPLICATION WHICH WOULD REQUIRE A DIFFERENT ANSWER TO ANY QUESTION CONTAINED IN THIS APPLICATION, OR ANY
PERSONNEL STATEMENT WHICH IS MADE A PART OF THIS APPLICATION, SUCH CHANGE MUST BE REPORTED AS AN AMENDMENT
TO THIS APPLICATION AS SPECIFIED BY REVENUE DEPARTMENT REGULATIONS. THE FAILURE TO MAKE SUCH AMENDMENT SHALL
BE CAUSE FOR THE REVOCATION OF ANY LICENSE ISSUED PURSUANT TO THIS APPLICATION. INDICATE HERE THAT THIS IS FULLY
UNDERSTOOD. IF THERE HAS BEEN A CHANGE IN THE ABOVE INFORMATION DURING THE PAST YEAR (EXCEPT FOR MAILING ADDRESS),
DO NOT CHANGE THIS FORM. THIS INCLUDES OWNERSHIP, FINANCIAL, CONTRACTUAL, BUSINESS, OR ANY OTHER BENEFICIAL INTEREST.
IN SUCH CASE YOU MUST OBTAIN FROM THE DEPARTMENT AND RETURN AN APPROPRIATE APPLICATION FORM. YOUR SIGNATURE
ON THIS RENEWAL APPLICATION FORM CERTIFIES THAT YOU HAVE PREVIOUSLY FURNISHED ALL REQUIRED INFORMATION AND THAT
SUCH INFORMATION IS STILL TRUE AND CORRECT.
I DECLARE UNDER PENALTY OF PERJURY THAT THIS STATEMENT HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE
IS TRUE, CORRECT AND COMPLETE.
__________________________________________
__________________________________________
___________________________
Signature
Title
Date
(Must be signed by owner, partner, or authorized officer of corporation; stamped signature not acceptable)
I hereby certify that ______________________________ is personally known to me, that said applicant signed the foregoing
application after stating to me personal knowledge and understanding of all statements and answers made herein, and,
under oath actually administered by me, has sworn that said statements and answers are true.
THIS ____ DAY OF ______________, 20_____.
_________________________________
NOTARY PUBLIC
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