Boe-400-Acts - Application For Licensed Cigarette Distributor To Register Cigarette Tax Stamp Purchaser Form

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BOE-400-ACTS (FRONT) REV. 2 (6-07)
STATE OF CALIFORNIA
APPLICATION FOR LICENSED CIGARETTE DISTRIBUTOR TO REGISTER
BOARD OF EQUALIZATION
CIGARETTE TAX STAMP PURCHASER
Please print or type - instructions are available on the reverse of this form.
1. THIS APPLICATION IS FOR CIGARETTE TAX STAMP PURCHASER (please check one)
New
Revised
Reinstatement
INFORMATION ABOUT BOE ACCOUNT FOR wHICH CIGARETTE TAX STAMPS wILL BE PURCHASED
2. CIGARETTE DISTRIBUTOR ACCOUNT NUMBER
CR ET 02-
3. CIGARETTE DISTRIBUTOR NAME
4. CIGARETTE DISTRIBUTOR E-MAIL ADDRESS
AUTHORIzED CIGARETTE TAX STAMP PURCHASER FOR THE ABOvE ACCOUNT
5. NAME OF PERSON AUTHORIZED TO PURCHASE CIGARETTE TAX STAMPS
IS PURCHASER REGISTERED FOR ANOTHER CIGARETTE DISTRIBUTOR ACCOUNT? (check one)
Yes
No If yes, Account No. __________________________
6. CONTACT PHONE NUMBER
7. FAX NUMBER
8. E-MAIL ADDRESS OF PERSON AUTHORIZED TO PURCHASE STAMPS
9. PLEASE COMPLETE THE FOLLOWING FOR AUTHENTICATION OR IDENTIFICATION
Personal Identification Code (must be four numeric digits):
10. DOES THE PURCHASER INTEND TO ORDER CIGARETTE TAX STAMPS THROUGH THE INTERNET?
Yes
No
11. NAME AND TITLE OF THE DISTRIBUTOR’S PRINCIPAL OWNER OR AUTHORIZED REPRESENTATIVE
12. SIGNATURE OF THE DISTRIBUTOR’S PRINCIPAL OWNER OR AUTHORIZED REPRESENTATIVE
DATE
-
NOTE TO SIGNATORy: If you are not a corporate officer, partner, or owner, this signature certifies under penalty of perjury that you
hold a power of attorney to authorize permission to order cigarette stamps.
13. SIGNATURE OF AUTHORIZED PURCHASER
DATE
-
CLEAR
PRINT

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