Form 336 - Tobacco Tax License Application
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Michigan Department of Treasury
336 (Rev. 04-13)
The license year runs from
July 1, 2013, through June 30, 2014
Tobacco Tax License Application
Issued under authority of Public Act 327 of 1993 as amended.
New License
Renewal
PArT 1: Business informATion
Legal Name of Business
Account # (FEIN, TR or ME)
Business Organization:
Individual/Sole Proprietor
Corporation
LLC or LLP
Other: _________________________________
Operating Name of Business or DBA
Business Telephone Number
Business Fax Number
Legal Address
City
State
ZIP Code
Mailing Address of Business (Street or P.O. Box)
City
State
ZIP Code
Address Where Tobacco Products are Received, Stored and Sold (Street)
City
State
ZIP Code
Is this building owned or leased?
Owned
Leased
Lease Expiration Date:___________.
If leased, you must attach a copy of the current lease to this application.
Days of Week in Operation
Hours of Operation
License Contact Person Name
Telephone Number
Fax Number
E-mail Address
Tobacco Tax Return Preparer Name
Telephone Number
Fax Number
E-mail Address
PArT 2: Business oWners AnD oPerATors
Provide the following information for EACH and EVERY business owner, officer, partner, member, and other persons authorized to
make purchasing decisions for this company. Attach additional sheets if necessary.
Name
Title
Home Telephone Number
Social Security Number
Residential Street Address
City
State
ZIP Code
Are you a United States citizen?
Driver’s License Number
State of Issuance
Date of Birth
Yes
No
Name
Title
Home Telephone Number
Social Security Number
Residential Street Address
City
State
ZIP Code
Are you a United States citizen?
Driver’s License Number
State of Issuance
Date of Birth
Yes
No
Name
Title
Home Telephone Number
Social Security Number
Residential Street Address
City
State
ZIP Code
Are you a United States citizen?
Driver’s License Number
State of Issuance
Date of Birth
Yes
No
Name
Title
Home Telephone Number
Social Security Number
Residential Street Address
City
State
ZIP Code
Are you a United States citizen?
Driver’s License Number
State of Issuance
Date of Birth
Yes
No
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