Iowa Retail Permit Application For Cigarette/tobacco/nicotine/vapor printable pdf download

Iowa Retail Permit Application For

Iowa Department of Revenue

Cigarette/Tobacco/Nicotine/Vapor

https://tax.iowa.gov

SEE INSTRUCTIONS ON THE REVERSE SIDE

For period (MM/DD/YYYY) _____ / _____ / _____ through June 30, ______

I/we apply for a retail permit to sell cigarettes, tobacco, alternative nicotine, or vapor products:

Business Information:

Trade Name/DBA: ___________________________________________________________________

Physical Location Address: ___________________________ City: ________________ ZIP: _______

Mailing Address: ________________________ City: ________________ State: _____ ZIP: _______

Business Phone Number: (

) ___________

Legal Ownership Information:

Sole Proprietor 

Partnership 

Corporation 

LLC 

LLP 

Type of Ownership:

Name of sole proprietor, partnership, corporation, LLC, or LLP:

Mailing Address: ________________________ City: ________________ State: _____ ZIP: _______

Phone Number: (

)

Fax Number: ( ____ ) ________ Email:

Retail Information:

Over-the-counter 

Vending machine 

Types of Sales:

Types of Products Sold: (Check all that apply)

Cigarettes 

Tobacco 

Alternative Nicotine Products 

Vapor Products 

Type of Establishment: (Select the option that best describes the establishment)

Alternative nicotine/vapor store 

Bar 

Convenience store/gas station 

Drug store 

Grocery store 

Hotel/motel 

Liquor store 

Restaurant 

Tobacco store 

Has vending machine that assembles cigarettes 

Other  ________________________________

If application is approved and permit granted, I/we do hereby bind ourselves to a faithful observance of

the laws governing the sale of cigarettes, tobacco, alternative nicotine, and vapor products.

SIGNATURE OF OWNER(S), PARTNER(S), OR CORPORATE OFFICIAL(S)

Name (please print): _______________________

Signature: _______________________________

Date: ___________________________________

Send this completed application and the applicable fee to your local jurisdiction.

If you have any

questions contact your city clerk (within city limits) or your county auditor (outside city limits).

FOR CITY CLERK/COUNTY AUDITOR ONLY – MUST BE COMPLETE

 Fill in the amount paid for the permit:

Send completed/approved application to Iowa Alcoholic

Beverages Division within 30 days of issuance. Make sure

 Fill in the date the permit was approved

the information on the application is complete and

by the council or board:

accurate. A copy of the permit does not need to be sent;

 Fill in the permit number issued by

only the application is required.

It is preferred that

the city/county:

applications are sent via email, as this allows for a receipt



Fill in the name of the city or county

confirmation to be sent to the local authority.

issuing the permit:



Email:

 Fax: 515-281-7375

70-014a (03/15/2016)

Iowa Retail Permit Application For Cigarette/tobacco/nicotine/vapor

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