Form M-100a - Application To Purchase Cigarette Tax Stamps

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STATE OF HAWAII — DEPARTMENT OF TAXATION
FORM M-100A
(REV. 2013)
APPLICATION TO PURCHASE CIGARETTE TAX STAMPS
Initial Application
Amended Application (This supercedes all previous applications.)
Information About the Licensee
Cigarette Tax and Tobacco Tax License Number ______
Name
DBA
Check one:
Wholesaler
Type of organization (e.g. Corporation, Partnership, Individual, etc.)
Dealer
Hawaii Tax Identification
Number: W __ __ __ __ __ __ __ __ - __ __
Address
SSN/FEIN:
Telephone number:
______________________
City or town
State
Postal/ZIP Code
List the owners, partners, members, or principal corporate officers (Attach additional sheet if needed) Please print.
SSN/FEIN
Title
Address
Phone No.
Name
I declare, under the penalties set forth in section 231-36, HRS, that the information contained in this application has been
examined by me and, to the best of my knowledge and belief, is true and correct.
Signature of Owner, Partner, Member, or Principal Corporate Officer
Date
Print Name of Signatory
Title
DEPARTMENT OF TAXATION USE ONLY
Upon approval, the above named licensee is authorized to purchase Hawaii Cigarette Tax Stamps.
APPROVED BY ________________________ Approval Number CIG-
FORM M-100A

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