Fillable Application For Distributor'S License Form

ADDITIONAL INFORMATION REQUIRED FROM APPLICANTS

What is the nature of your business that requires an Oregon license?

In what area (cities) do you plan to distribute in Oregon?

List the name, address, and telephone number of your suppliers:

(attach additional pages as necessary)

List each manufacturer’s name and the warehouse address from which you receive your supply:

(attach additional pages as necessary)

Manufacturer’s name

Warehouse address

City, state, ZIP code

Identify other licenses issued to you for cigarette and tobacco products for any other state:

(attach additional pages as necessary)

Type of license (cigarette, tobacco products, etc.)

State

Will you use Oregon cigarette tax stamps on products that you distribute? Yes No. If yes, explain how and where you will af-

fix the stamps for distribution.

Does the business being conducted violate any Oregon law? Yes No

Have you (applicant), or any other person listed on this application, ever been denied a permit, license, or other authorization to engage

in any business to manufacture, export, or import tobacco products by any government agency (federal, state, local, or foreign), or had

such permit, license, or other authorization revoked, suspended, or otherwise terminated? Yes No. If yes, you must explain.

Consent to search for contraband product

For the purpose of enforcing Oregon’s cigarette tax and anti-contraband cigarette laws, I hereby consent to the inspection and examination by

the Oregon Department of Revenue and its authorized agents of any books, records (including Oregon cigarette tax stamps), receipts, invoices,

equipment relating to cigarettes; cigarette packs, cigarette cartons; or any other storage container designed or used to store cigarettes or any

other pertinent document or equipment related to the sale, purchase, storage, tax stamp application, or transportation of cigarettes.

Federal Privacy Act Information

Under the general authority of OAR 150-305.100, the Social Security numbers of all company officers of distributorships must be included in

the application for a distributor’s license. This information is to be used primarily by the Oregon Department of Revenue for identification and

compliance purposes in the administration of the Oregon Cigarette Tax Act and the Oregon Tobacco Products Tax Act. Oregon law permits

disclosure of such information to governmental units outside Oregon, which also tax tobacco products and which grant reciprocal rights.

Signing this application acknowledges awareness of the requirements of the Jenkins Act (Title 15, U.S.C. Sect. 375 et. seq.). This act requires

distributors to file reports with the taxing authority of the state where cigarettes are shipped to persons other than another licensed distributor.

The report must include the total number of cigarettes shipped, and the complete name and address of the person receiving the cigarettes.

I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document and to the best of my knowledge, it is

true, correct, and complete.

Social Security number

Signature

Title

Date

150-105-001 (Rev. 12-09)

Application For Distributor'S License Form - Oregon Page 2