Application For Distributor'S License Form - Oregon
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APPLICATION FOR
FOR DEPARTMENT OF REVENUE USE ONLY
DISTRIBUTOR / WHOLESALER
Date received
BIN
LICENSE
Cigarette license number
Date license issued
Cigarette distributor
Tobacco license number
Approved by
Tobacco products distributor
• You must also complete
Cigarette wholesaler
the back of this form.
Business name
Business registry number
Federal employer ID number (FEIN)
City
County
State
ZIP code
Physical street address
Telephone number
Mailing address
City
ZIP code
State
(if different from above)
(
)
Physical location of business records
City
ZIP code
Telephone number
State
(
)
Fax number for business records
Contact person
Telephone number
(
)
(
)
Date business started
Type of organization
Individual
Partnership
Corporation
S Corporation
Other: ____________________
Names of owners, partners, shareholders, or corporation officers:
Street address
City, state, ZIP code
Social Security number
Name
Employer status
Are you an employer?
Yes (nonexempt)
No (exempt*)
If yes, you must provide:
WCD seven-digit compliance number OR name of carrier and policy number: _________________________________________
*All-family business may be exempt form workers’ compensation. Contact the Workers’ Compensation Division to determine eligibility, 503-947-7815.
Nature of business
Manufacturer
Common carrier
Wholesaler
Within Oregon
Internet sales
Distributor
Retailer
Importer
Outside Oregon
Other: ______________________
Source of product supply
Manufacturer’s warehouse stock
Imported direct from outside Oregon
Manufactured in Oregon
From other licensed distributors
Cigarette tax stamps
Method of payment:
Cash
or
Deferred payment
(requires deposit of a bond)
Method of shipment:
Pick-up or
Courier: Name _________________________ Courier account no. _____________
Average number of cigarettes (with Oregon stamps) to be distributed during the year: _______________________
Contact person’s name and telephone number: ____________________________________________________________________
Additional information on the back
150-105-001 (Rev. 12-09)
Mail completed application to: Cigarette/Tobacco Tax
Oregon Department of Revenue
PO Box 14630
Salem OR 97309-5050
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