Form Otp-901 - Application For Other Tobacco Products Distributor'S License - 2007
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2INDIANA DEPARTMENT OF REVENUE
P.O. BOX 901
FOR OFFICE ONLY
INDIANAPOLIS, IN 46206-0901
OTP
This form must be submitted 30 days prior to:
a) the expiration of your current license or,
b) the date you begin your business
OTP-901
R3/ 10-07
You may not do business without your certifi cate.
APPLICATION FOR OTHER TOBACCO PRODUCTS DISTRIBUTOR’S LICENSE
Renewal
New Certifi cate
Applicant’s Name - Enter individual’s, partnership’s, or corporation’s name
Federal ID Number
Business/Trade Name (if different than above)
Telephone Number
Owner’s Social Security #
Mailing Address (Street or P.O. Box Number)
City or Town
County
State
Zip Code
Location Address of Business (if different than above)
City or Town
County
State
Zip Code
Type of Ownership:
Sole Proprietorship
Partnership
Corporation
If Corporation: Date of Incorporation:___________________________________
If Foreign Corporation: Date of Acceptance by Indiana Secretary of State:______________________________________________
If an Indiana corporation or a foreign corporation, give name and address of Resident Agent:________________________________
Identifi cation of Partners or Corporate Offi cers
Name (last name fi rst)
Social Security Number
Address
City
State
Zip Code
Title
Reason License Needed (Answer Yes or No):
New Business:
Purchase of Existing Business:
Lease of Existing Business:
From Whom Was Business Purchased or Leased?
Reinstatement of Old License:
Does Applicant Presently Hold a Cigarette Tax License? ________________ License Number:___________________________
Has Applicant Previously Held a Cigarette Tax License? ________________ License Number:___________________________
Does Applicant Presently Hold an Indiana Registered Retail Merchants Certifi cate? _________ Certifi cate Number:_______________________________
Does Applicant Presently Hold Any Other Licenses or Permits Issued by any State Agency?
STATE AGENCY
TYPE OF LICENSE OR PERMIT
NUMBER
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