Form 336 - Tobacco Products Tax License Application - 2009 Page 2
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4336, Page 2
PART 3: TOBACCO PRODUCTS TAX LICENSE TYPES AND FEES
Check the appropriate license type(s) for which you wish to apply. If you currently have license(s) issued review them to identify the type(s)
that you have. See page 4 for descriptions of each license type.
TYPE
LICENSE FEE
$10
Unclassified Acquirer of Other Tobacco Products
$100
Unclassified Acquirer of Cigarettes
Cig
OTP
Both
$25 plus an additional $6.25 for each branch location
Secondary Wholesaler
Cig
OTP
Both
$25 plus an additional $6.25 for each additional storage location.
Vending Machine
$100
Manufacturer
Cig
RYO
OTP
(Incl. Cigars, Hookah)
Non-Participating in MSA (NPM)
Participating in MSA (PM)
Product
Wholesaler
Cig
OTP
Both
$100
Transporter
Cig
OTP
Both
$50
Transportation Company
Cig
OTP
Both
$5
PART 4: LIST COMPANIES FROM WHICH YOU WILL PURCHASE TOBACCO PRODUCT(S)
Complete each line, enter N/A if not applicable. If you are applying to be licensed as an unclassified acquirer, wholesaler, secondary
wholesaler, vending machine operator, transporter, or transportation company of other tobacco products and/or cigarettes, complete the
following information on the companies from which you are acquiring tobacco products. You may attach additional sheets if necessary.
Enter (P) for Participating or Product
Enter (C) for Cigarette, (R) for
Brand Name (Required
Manufacturer, (N) for
Company Name and Address Enter (T) for Tax Paid,
Roll Your Own, (O) for Other
for Cigarette and Roll
Non-Participating Manufacturer, (D)
(U) for Tax Unpaid
Tobacco Product
Your Own only)
for Out of State Distributor.
18.
19.
20.
PART 5: ADDITIONAL INFORMATION FOR VENDING MACHINE OPERATOR LICENSE APPLICANTS
If you are applying for a vending machine operator license, list the number of vending machines in use, the number in
storage and the business name and address where each machine is located. Attach additional sheets if necessary. Complete
each line. Enter N/A if not applicable.
21. Number of Vending Machines in Use
22. Number of Vending Machines in Storage
23. Total number of Vending Machines
24. Business Name and Address for each Vending Machine location.
PART 6: ADDITIONAL INFORMATION FOR MANUFACTURER'S LICENSE APPLICATION
Attach additional sheets if necessary. Complete each line. Enter N/A if not applicable.
Brand Name
Enter (C) for Cigarette, (RYO) for Roll-Your-Own
(Required for Cigarette and Roll-Your-Own Only)
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