Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application Page 2

Download a blank fillable Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

SECTION 4 - OWNERSHIP INFORMATION - IDENTIFY OWNERS, OFFICERS, PARTNERS, MEMBERS

(ATTACH LIST IF ADDITIONAL SPACE IS REQUIRED.)

Reset Section 4

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

SOCIAL SECURITY NUMBER

BIRTHDATE (MM/DD/YY)

___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___

HOME ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EFFECTIVE DATE OF TITLE

__ __ __ __ __

___ ___ / ___ ___ / ___ ___

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

SOCIAL SECURITY NUMBER

BIRTHDATE (MM/DD/YY)

___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___

HOME ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EFFECTIVE DATE OF TITLE

__ __ __ __ __

___ ___ / ___ ___ / ___ ___

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

SOCIAL SECURITY NUMBER

BIRTHDATE (MM/DD/YY)

___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___

HOME ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EFFECTIVE DATE OF TITLE

__ __ __ __ __

___ ___ / ___ ___ / ___ ___

SECTION 5 - PREVIOUS OWNER INFORMATION

Reset Section 5

NAME OF PREVIOUS OWNER

NAME OF PREVIOUS BUSINESS

PREVIOUS LICENSE NUMBER

DATE BUSINESS CLOSED

__ __ / __ __ / __ __

PREVIOUS BUSINESS ADDRESS

CITY

STATE

ZIP CODE

COUNTY

__ __ __ __ __

SECTION 6 - NAMES OF ANY PERSONS ASSOCIATED WITH THIS COMPANY WHO PRESENTLY OR PREVIOUSLY OWNED, OPERATED,

OR MANAGED ANOTHER CIGARETTE OR TOBACCO COMPANY. (ATTACH A LIST IF ADDITIONAL SPACE REQUIRED.)

COMPANY NAME

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

HOME ADDRESS

CITY

STATE

ZIP CODE

LICENSE NUMBERS

__ __ __ __ __

SOCIAL SECURITY NUMBER

BIRTHDATE (MM/DD/YYYY)

___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ / ___ ___ / ___ ___ ___ ___

COMPANY NAME

NAME (LAST, FIRST, MIDDLE INITIAL)

TITLE

HOME ADDRESS

CITY

STATE

ZIP CODE

LICENSE NUMBERS

__ __ __ __ __

SOCIAL SECURITY NUMBER

BIRTHDATE (MM/DD/YYYY)

Reset Page 2 Section 6

___ ___ / ___ ___ / ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___ ___

SECTION 7 - 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 other tobacco products) direct from the manufacturer. Please list all manufacturers, including names, complete addresses,

and telephone numbers. Attach letters of recommendation from major manufacturers for cigarette licenses. Attach additional sheet if necessary.

Reset This Section

Manufacturer Name

Address

Telephone Number

( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Purchase product from Missouri licensed wholesalers. Please list all licensed wholesaler names and license numbers, and indicate whether product being purchased is cigarette

or OTP. If product is cigarette, indicate whether product is stamped, tax paid or unstamped, tax unpaid. If product is OTP, indicate whether product is tax paid or unpaid. Attach

additional sheet if necessary.

Missouri Licensed Wholesaler Name

License Number

Cigarette

OTP

Stamped/Tax Paid

Not Stamped/Tax Unpaid

Reset This Section

DOR-2175 (08-2012)