Ctp-200 - Application For Cigarette And Tobacco Products Retail License - Wisconsin Department Of Revenue
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Application for Cigarette and
MUNICIPAL USE ONLY
Tobacco Products Retail License
License Number
Submit to municipal clerk.
Period Covered
Applicant’s Wisconsin 15-digit Sales Tax Account Number
Date of Issuance
This must be issued in the same
Legal Name of the licensee below.
Federal Employer Identification No. (FEIN)
Legal Name
(corporation, limited liability company, partnership or sole proprietorship)
Trade or Business Name (if different than Legal Name)
Telephone Number
(
)
Business Address (License Location)
Business Located In
Business Telephone
(
)
City
Village
Town
City
State
ZIP Code
County
of:
Mailing Address (if different than Business Address)
City
State
ZIP Code
Organization (check one)
Sole Proprietor
Wisconsin Corporation – Enter date incorporated:
Partnership
Out-of-State Corporation – Are you registered to do business in Wisconsin?
YES
NO
Other (describe)
1. Does the applicant understand that they must purchase cigarettes only from distributors or jobbers
YES
NO
who hold a permit with the Wisconsin Department of Revenue?
2. Does the applicant understand that they must obtain a Tobacco Products Distributor permit if purchasing
YES
NO
untaxed tobacco products from an out-of-state company? (Tobacco Products Distributor permit is
available from the Wisconsin Department of Revenue at 608-261-6435. See application form CTP-
129, revenue.wi.gov/forms/excise/ctp-129.pdf.)
YES
NO
3. Does the applicant understand that they cannot purchase/exchange cigarettes or tobacco products
from another retailer, including transferring existing stock to a new owner?
YES
NO
4. Does the applicant understand that they must provide employees with tobacco sales training approved
by the Wisconsin Department of Health Services? ()
YES
NO
5. Does the applicant understand that they may not sell, give or otherwise provide cigarettes/tobacco
products and nicotine products to minors (including electronic cigarettes containing nicotine)?
6. Does the applicant understand that they may not sell single cigarettes?
YES
NO
7. Does the applicant understand that cigarette and tobacco products invoices must be kept on the
YES
NO
licensed premises for two years from the date of the invoice and be available for inspection by the
Wisconsin Department of Revenue/law enforcement and that failure to comply can result in criminal
penalties, including loss of cigarettes/tobacco products?
8. Does the applicant understand that only cigarettes and roll-your-own (RYO) tobacco products listed on
YES
NO
the Wisconsin Department of Justice’s website labeled “Directory of Certified Tobacco Manufacturers
and Brands” at
may be sold in Wisconsin?
Cigarettes / Tobacco will be sold
over counter
through vending machine
both
READ CAREFULLY BEFORE SIGNING: Under penalty provided by law, the applicant states that each of the above questions has
been truthfully answered to the best of the knowledge of the applicant. Applicant agrees to operate this business according to law and
that the rights and responsibilities conferred by the license(s), if granted, cannot be assigned to another.
Any lack of access to any portion of a licensed premises during inspection will be deemed a refusal to permit inspection. Such refusal
is a misdemeanor and grounds for revocation of this license.
(Officer of Corporation /Member/Manager of Limited Liability Company/Partner/Individual)
SUBSCRIBED AND SWORN TO BEFORE ME
this
day of
, 20
(Clerk / Notary Public)
My commission expires
CTP-200 (R. 9-15)
Wisconsin Department of Revenue
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