Form Ct-5 - Application For Cigarette Wholesale Dealer And/or Tobacco Distributor License
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1VERMONT DEPARTMENT OF TAXES
APPLICATION FOR
CIGARETTE WHOLESALE DEALER AND/OR
TOBACCO DISTRIBUTOR LICENSE
Please print or type. Incomplete and/or illegible applications will be returned.
Reason for Application
Cigarette Wholesale Dealer
Tobacco Wholesale Distributor
Both
Name of Applicant*
Telephone Number
Federal ID Number
Name of Contact Person
E-mail address
Telephone Number
Trade Name of Business
Mailing Address
Street, Road or PO Box
City
State
Zip Code
Physical Location of Business
Street (NO PO BOX)
City
State
Location of Accounting Records
Street or Road (NO PO BOX)
City
State
Zip Code
* If the applicant is a corporation, partnership, or LLC, list all persons with 10% or more ownership interest below.
If the applicant is a corporation, partnership, or LLC, list principal owners (ownership interest of 10% or more).
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Principal owner name
Address
City
State
ZIP Code
Applicant must sign this form.
Signature of Applicant
Date
Printed Name
Title
MAIL THIS APPLICATION TO:
VERMONT DEPARTMENT OF TAXES, 133 STATE STREET, MONTPELIER, VT 05633-1401
Form CT-5
(Rev. 7/06)
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Parent category: Financial