Form 2175 - Cigarette/other Tobacco Products Tax License Application - Missouri Department Of Revenue - 2003

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FOR OFFICE USE ONLY

MISSOURI DEPARTMENT OF REVENUE

FORM

DIVISION OF TAXATION & COLLECTION

LICENSE NUMBER

2175

P.O. BOX 811, JEFFERSON CITY, MO 65105-0811

CIGARETTE/OTHER TOBACCO PRODUCTS

(REV. 12-2003)

DATE ISSUED

CHECK NUMBER

TAX LICENSE APPLICATION

$100.00 FEE IS REQUIRED WITH APPLICATION (MAKE CHECK PAYABLE TO THE “DEPARTMENT OF REVENUE”).

TYPE OF APPLICATION:

REGISTERING FOR:

NEW LICENSE

CIGARETTE WHOLESALER’S LICENSE

OTHER TOBACCO PRODUCTS LICENSE

BOTH

RENEWAL

DATE BUSINESS OPENED

TYPE OF OWNERSHIP

SOLE PROPRIETORSHIP

MISSOURI CORPORATION

MISSOURI CHARTER NUMBER

PARTNERSHIP

FOREIGN CORPORATION

CERTIFICATE OF AUTHORITY NUMBER

LIMITED LIABILITY CO.

LIMITED PARTNERSHIP

LIMITED PARTNERSHIP NUMBER

OTHER

OUT-OF-STATE APPLICANTS MUST SUBMIT A COPY OF THE COMPANY’S CERTIFICATE OF GOOD STANDING AND A COPY OF THE CIGARETTE WHOLESALER AND/OR OTHER TOBACCO

PRODUCTS LICENSE FOR THE COMPANY’S HOME STATE.

BUSINESS NAME AND PHYSICAL LOCATION

The license will be issued to this address. Inventory must be kept at this address and cigarettes stamped here. We will only ship decals to this address.

COMPANY NAME

MITS NUMBER

DOING BUSINESS AS

FEIN

STREET

TELEPHONE NUMBER

CITY

STATE

ZIP CODE

FAX NUMBER

CONTACT PERSON (List name of person to contact regarding license application)

NAME

TITLE

TELEPHONE NUMBER

E-MAIL ADDRESS

BUSINESS MAILING ADDRESS

RECORD STORAGE ADDRESS

(DO NOT USE PO BOX NUMBER)

STREET, ROUTE OR PO BOX NUMBER

CITY

STREET, HIGHWAY, COMMUNITY

CITY

STATE

ZIP CODE

COUNTY

STATE

ZIP CODE

COUNTY

BUSINESS ACTIVITIES

(DESCRIBE ACTIVITY AND CHECK ALL BOXES THAT APPLY TO YOUR BUSINESS.)

RETAIL

WHOLESALE

MANUFACTURER

OTHER

DESCRIBE THE PRIMARY BUSINESS ACTIVITY:

PURCHASE ALL PRODUCTS (UNSTAMPED CIGARETTES AND/OR OTHER TOBACCO PRODUCTS) DIRECT FROM THE MANUFACTURER. ATTACH LIST OF MANUFACTURERS, INCLUDING

NAMES, COMPLETE ADDRESSES, AND TELEPHONE NUMBERS.

PURCHASE OTHER TOBACCO PRODUCTS FROM SUPPLIERS THAT ARE NOT MISSOURI LICENSED WHOLESALERS. ATTACH LIST OF SUPPLIERS, INCLUDING NAMES, COMPLETE

ADDRESSES, AND TELEPHONE NUMBERS.

OPERATE RETAIL STORES WHERE CIGARETTES AND/OR OTHER TOBACCO PRODUCTS ARE SOLD. ATTACH LIST OF LOCATIONS, INCLUDING TAX NUMBER OF EACH LOCATION.

OWN, OPERATE, AND/OR SERVICE CIGARETTE VENDING MACHINES, AND/OR HUMIDORS. ATTACH LIST SHOWING NAME AND ADDRESS OF EACH LOCATION.

BUY AND/OR SELL TOBACCO PRODUCTS ON THE INTERNET. WEBSITE ADDRESS: _________________________________________________________________________________________

BUY AND/OR SELL TOBACCO PRODUCTS BY TELEPHONE SALES.

BUY AND/OR SELL TOBACCO PRODUCTS BY CATALOG SALES. PLEASE ATTACH A COPY OF YOUR CATALOG.

PLACE OTHER TOBACCO PRODUCTS IN RETAIL LOCATIONS ON CONSIGNMENT. ATTACH LIST SHOWING NAME AND ADDRESS OF EACH LOCATION AND A SAMPLE COPY OF CONTRACT

BETWEEN YOU AND THE RETAILER.

PREVIOUS OWNER INFORMATION

NAME OF PREVIOUS OWNER

NAME OF PREVIOUS BUSINESS

PREVIOUS LICENSE NUMBER

DATE BUSINESS CLOSED

PREVIOUS BUSINESS ADDRESS

CITY

STATE

ZIP CODE

COUNTY

If you have questions or need assistance in completing this form, please call (573) 751-7163 or e-mail excise@dor.mo.gov. You may also access the department’s

web site at TDD: (800) 735-2966

This publication is available upon request in alternative accessible format(s).

MO 860-0627 (12-2003)