Form Ador 74-4028 - Application For Registration To Sell Tobacco Products Form- For Distributors Of Tobacco Products - Arizona Department Of Revenue
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1
2Arizona Department of Revenue
Arizona Department of Revenue • • Tobacco Tax
Tobacco Tax
1600 West Monroe, Phoenix, AZ, 85007
1600 West Monroe, Phoenix, AZ, 85007
For assistance call (602) 716-6458 or (602) 716-6457
For assistance call (602) 716-6458 or (602) 716-6457
Application for Registration to Sell Tobacco Products - For Distributors of Tobacco Products
Application for Registration to Sell Tobacco Products - For Distributors of Tobacco Products
Upon application for this tobacco license you are bound by Arizona State Tobacco Tax Statutes and other
Upon application for this tobacco license you are bound by Arizona State Tobacco Tax Statutes and other
regulatory requirements imposed on tobacco distributors by the Arizona Department of Revenue.
regulatory requirements imposed on tobacco distributors by the Arizona Department of Revenue.
The tobacco license is required for distributors who make the fi rst sale of cigarettes without tax stamps affi xed, or cigars
or other tobacco products upon which taxes have been paid in the state. Distributors must also pay the tax and/or affi x
tobacco tax stamps prior to selling these products. For assistance with payment of tax and reporting sales of tobacco
products, please call the telephone number shown above.
Section I:
Section I:
Ownership
Ownership
TYPE OF OWNERSHIP:
Individual
Sub Chapter S Corporation
Limited Liability Company
Limited Liability Partnership
Partnership
State of Incorporation: __________
Date of Incorporation: _______________
Other
Section II:
Section II: Business Information
Business Information
LEGAL BUSINESS NAME:
IN CARE OF
CHECK THE BOXES APPLICABLE TO YOUR BUSINESS:
OTP (Other Tobacco Products)
Cigarettes (unstamped)
BUSINESS (OR DBA) NAME
BUSINESS TELEPHONE (INCLUDE AREA CODE)
(
)
BUSINESS FAX NUMBER (INCLUDE AREA CODE)
FEDERAL EMPLOYER IDENTIFICATION NUMBER
TRANSACTION PRIVILEGE TAX NUMBER
(
)
MAILING ADDRESS (STREET, ROUTE, OR P.O. BOX)
CITY
STATE
ZIP CODE
PRIMARY LOCATION OF BUSINESS (PHYSICAL ADDRESS)
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
Section III:
Section III: Owners / Partners / Corporation Offi cers Identifi cation
Owners / Partners / Corporation Offi cers Identifi cation
SOCIAL SECURITY NUMBER
NAME
TITLE
% OWNED
COMPLETE RESIDENCE ADDRESS
RESIDENT PHONE
(
)
(
)
(
)
(
)
Please check here if any of the principals listed above have ever been convicted of a class 5 felony under
ARS §42-1127.D for “selling or offering for sale, in an unstamped or unlawfully stamped condition, 10,000 or more
cigarettes that were subject to tax.” Persons convicted under this statute are permanently ineligible to hold a license.
Section IV:
Section IV: Location of Records (For Audit Purposes)
Location of Records (For Audit Purposes)
NAME OF COMPANY OR PERSON TO CONTACT
PHONE NUMBER (INCLUDE AREA CODE)
(
)
STREET NO. & NAME (NO P.O. BOX OR RT. NO.)
CITY
STATE
ZIP CODE
This application must be signed by either a sole proprietor, two partners, two corporate offi cers. Submit the application to
the address above with $25 annual license fee.
Under penalty of perjury I (we) declare that the information in this document is true, correct and complete.
PRINT NAME
SIGNATURE
DATE
PRINT NAME
SIGNATURE
DATE
ADOR 74-4028 (9/03)
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