SECTION 9 - CIGARETTE TAX STAMP PURCHASING INFORMATION
Indicate your shipping method for cigarette tax stamps (Wholesaler is responsible for shipping costs):
UPS Number:____________________________________
FedEx Number:___________________________________
Check the appropriate box indicating how you wish to purchase cigarette tax stamps:
Cash Basis (No Bond Required)
Credit Basis*
Cash and Credit Basis*
* Must post bond for amount of credit desired.
SECTION 10 - BOND INFORMATION
Check the appropriate box indicating which type of bond you will be acquiring:
Cigarette Wholesaler Bond (required only for wholesalers purchasing cigarette tax stamps on credit)
Letter of Credit
Surety Bond
Cash Bond
Other Tobacco Products Bond*
Letter of Credit
Surety Bond
Cash Bond
* Other Tobacco Products licensees are required to maintain a bond in the amount of three times the average tax liability, with a $500 minimum. Upon review, if the Director of Revenue
deems your current bond insufficient to cover the liability, the bond requirement will be adjusted to a satisfactory level in accordance with your current tax liability.
Reset Section 11
SECTION 11 - REPORTING FORMS - ALL APPLICANTS MUST COMPLETE THIS SECTION
If you are licensed for cigarette or other tobacco products in other states, please list the state and all license numbers.
State
License Number
State
License Number
How do you want to receive reporting forms and updates? (Check one)
I will download from the Internet.
Please mail one set of forms on a yearly basis.
Form 5298 (Registration for Electronic Notification of Changes in the Missouri Tobacco Directory) attached.
Missouri Secretary of State Certificate of Organization attached. (Required unless business is owned by a sole proprietor)
SECTION 12 - SIGNATURE
The application must be signed by the owner if the business is a sole proprietorship; partner, if the business is a partnership; reported officer, if the business is a corporation or by
a member if the business is a L.L.C. as reported on this application. The signature MUST be of the owner, partner, or officer as reported on this application. I declare that the above
information and any attachments are true, complete, and correct. I further certify under the penalty of perjury that I will comply fully with sections 196.1020 through 196.1035, RSMo.
SIGNATURE
TITLE
DATE (MM/DD/YY)
___ ___ / ___ ___ / ___ ___
PLEASE TYPE OR PRINT NAME
4
DOR-2175 (08-2012)