Form 69-119 - Vending Machine Inventory Supplement For Cigarette And/or Tobacco Products Permit (Decal)

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69-119

VENDING MACHINE

*6911900W011705*

(Rev.1-17/5)

PRINT FORM

CLEAR FIELDS

INVENTORY SUPPLEMENT FOR CIGARETTE

*6911900W011705*

AND/OR TOBACCO PRODUCTS PERMIT (DECAL)

• Please type or print.

• Please attach additional sheets if necessary.

NOTE: Use this supplement to report your new vending machine inventory.

• Do not write in shaded areas

Legal name of owner

Taxpayer number

1(a) FOR THE MACHINE AT THIS LOCATION, PROVIDE THE FOLLOWING:

Comptroller Use Only

MACHINE MAKE

MACHINE MODEL

MACHINE

MACHINE "IN SERVICE"

PERMIT/DECAL

LATE

MISCAPP

OR MANUFACTURER

SERIAL/ID NUMBER

DATE

FEE 1(a)

FEE 1(b)

Job name -

Microfilm

Trade name of business where the cigarette/tobacco vending machine is located

Business phone (Area code and number)

(

)

00991

Commercial location address of the cigarette/tobacco vending machine

City

State

ZIP Code

County

8 8 8 1

Do you own the vending machine from which cigarettes and/or tobacco products will be sold? ..............................................

YES

If you do not own the vending machine, list the machine owner's name and mailing address:

Reference no.

Do you own the cigarettes and/or tobacco products displayed for sale in the vending machine? .............................................

YES

Where will business records for the vending machine be maintained? Use street address or directions, city, state and ZIP Code;

(NOT P.O. Box, rural route or public storage.) MUST BE A COMMERCIAL LOCATION:

2(a) FOR THE MACHINE AT THIS LOCATION, PROVIDE THE FOLLOWING:

MACHINE MAKE

MACHINE

MACHINE "IN SERVICE"

PERMIT/DECAL

LATE

OR MANUFACTURER

MODEL

SERIAL/ID NUMBER

DATE

FEE 2(a)

FEE 2(b)

Trade name of business where the cigarette/tobacco vending machine is located

Business phone (Area code and number)

(

)

Commercial location address of the cigarette/tobacco vending machine

City

State

ZIP Code

County

Do you own the vending machine from which cigarettes and/or tobacco products will be sold? ..............................................

YES

If you do not own the vending machine, list the machine owner's name and mailing address:

Do you own the cigarettes and/or tobacco products displayed for sale in the vending machine? .............................................

YES

Where will business records for the vending machine be maintained? Use street address or directions, city, state and ZIP Code;

(NOT P.O. Box, rural route or public storage.) MUST BE A COMMERCIAL LOCATION:

1. Permit fee due for vending machine listed above: 1(a)

1(b) Late Fee (if applicable): ....................

2. Permit fee due for vending machine listed above: 2(a)

2(b) Late Fee (if applicable): ....................

3. Sum of Permit Fees Due: 1(a) plus 2(a) .................3(a)

3(b) Sum of late fees due: 1(b) plus 2(b)

4. TOTAL AMOUNT DUE & PAYABLE:

3(a) plus 3(b)

The sole owner, all general partners, corporation president, vice-president, secretary or treasurer, or an

Date of application (Mo., day, year)

authorized representative must sign this application. The authorized representative must submit a written

power of attorney with application. (Attach additional sheets, if necessary.)

I (We) declare that the information in this document and any attachments is true and correct to the best of my (our) knowledge and belief.

Type or print name and title of sole owner, partner or officer, or authorized representative

Sole owner, partner or officer, or authorized representative

Type or print name and title of partner or officer, or authorized representative

Partner or officer, or authorized representative

Type or print name and title of partner or officer, or authorized representative

Partner or officer, or authorized representative

YOUR PERMIT MUST BE PROMINENTLY DISPLAYED IN YOUR PLACE OF BUSINESS.

DISCLOSURE OF INFORMATION PROVIDED ON THIS FORM WILL BE GOVERNED BY THE

TEXAS PUBLIC INFORMATION ACT, GOVERNMENT CODE, CHAPTER 552.

Under Ch.559, Government Code, you are entitled to review, request and correct information we have on file about you, with limited exceptions in accordance with Ch. 552, Government Code.

To request information for review or to request error correction, contact us at the address or phone numbers listed on this form.

Mail your completed application with the required permit fee to:

Make check payable to:

COMPTROLLER OF PUBLIC ACCOUNTS

STATE COMPTROLLER

111 E. 17th Street Austin, TX 78774-0100