Form Ador 14-4028 - License Application For Distributors Of Tobacco Products

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Arizona Department of Revenue

Arizona Department of Revenue • • Tobacco Tax

Tobacco Tax

1600 West Monroe, Phoenix, AZ 85007

For assistance, call (602) 716-7808

• •

License Application for Distributors of Tobacco Products

By applying for a tobacco license you agree to be bound by all Arizona tobacco tax statutes and other regulatory

requirements imposed on tobacco distributors by the Arizona Department of Revenue (ADOR).

All distributors who make the initial sale or distribution in this state of tobacco products upon which Arizona taxes have not been paid must hold valid tobacco licenses

issued by ADOR. Distributors must also pay Arizona tobacco taxes and, when applicable, afﬁ x tobacco tax stamps before selling these products. Persons selling

tobacco products without a valid license or payment of applicable taxes may be subject to civil and criminal penalties, including seizure and forfeiture of their tobacco

products. For assistance with payment of tobacco taxes and reporting sales of tobacco products, please call the telephone number provided above.

Section I: Ownership

If corporation, enter the:

TYPE OF OWNERSHIP:

Individual

Limited Liability Company

Subchapter C Corporation

State of Incorporation:

Partnership

Limited Liability Partnership

Subchapter S Corporation

Date of Incorporation:

Other: __________________________________

Section II: Business Information

LEGAL BUSINESS NAME:

IN CARE OF

DISTRIBUTOR TYPE (check all that apply):

Cigarette Distributor

Cigarette Manufacturer

Cigarette Importer

OTP Distributor

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: Identiﬁ cation of Owners / Partners / Corporate Ofﬁ cers

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 3 felony under A.R.S. § 42-1127(E), which includes transporting,

selling or offering for sale, in an unstamped or unlawfully stamped condition, 10,000 or more cigarettes that were subject to Arizona tobacco tax. Pursuant to

A.R.S. § 42-3201(E), persons convicted under this statute are permanently ineligible to hold a license.

Section IV: 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 Route Number)

CITY

STATE

ZIP CODE

Signature

This application must be signed by a sole proprietor, two partners, two managing members, or two corporate ofﬁ cers. Submit this application to the address above

with the $25 annual license fee.

LICENSES ARE NONTRANSFERABLE. IF THE BUSINESS IS SOLD OR TERMINATED, THE LICENSEE(S) LISTED BELOW SHALL NOTIFY ADOR IN WRITING

WITHIN THIRTY (30) DAYS OF THE SALE OR TERMINATION, PROVIDING THE DATE OF SALE OR TERMINATION.

Under penalty of perjury, I(we) declare that the information in this application is true, correct, and complete. Pursuant to A.R.S. § 42-3201, I(we) understand that

ADOR may make certain information provided in Sections I and II above available for public inspection on its web site, subject to the conﬁ dentiality requirements of

A.R.S. § 42-2003.

PRINT NAME

SIGNATURE

DATE

PRINT NAME

SIGNATURE

DATE

ADOR 14-4028 (10/06)