Form 336 - Tobacco Products Tax License Application - 2009 Page 3
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4336, Page 3
PART 7: OWNERSHIP INFORMATION
.
Complete each line. Enter N/A if not applicable
Lines 18-20 must be completed for each corporate officer, principal, partner or owner. Attach
additional sheet(s) if necessary.
A.
B.
C.
D.
E.
F.
Title
Full Legal Name
Residence Address
Residence
Social
Date of Birth
(First, Middle, Last)
(Street or RR#, City, State, ZIP Code)
Telephone Number
Security Number
25.
26.
27.
28. Has the corporation, LLC, LLP, partnership, or any officers, members,
29. Has the corporation, LLC, LLP, partnership, or any officers, members,
controlling shareholders of the corporation or owners of the business
controlling shareholders of the corporation or owners of the business had
been convicted of any felony or misdemeanor involving tobacco or any tax
a tobacco license revoked or refused for issuance or renewal in the State
issues?
of Michigan or another state or foreign jurisdiction?
Yes
No
Yes
No
If Yes, explain:
If Yes, explain:
30a. Has the corporation, LLC, LLP, partnership, or any officers,
30b. Has the corporation, LLC, LLP, partnership, or any officers,
members, controlling shareholders of the corporation or owners of the
members, controlling shareholders of the corporation or owners of the
business been licensed under another name in Michigan?
business ever been licensed in another state?
Yes
No
Yes
No
Name previously licensed under:______________________________
State currently or previously licensed under:_____________________
Account Number (FEIN, TR, ME):_____________________________
PART 8: CERTIFICATION (
This form must be signed by all persons listed in Part 7.)
By signing this application I agree to comply with P.A. 327 of 1993, as amended, and all applicable Letter Rulings. I declare under penalty of
perjury, that I have examined this application, including accompanying schedules and statements, and to the best of my knowledge, it is true
and complete. I authorize the Michigan Department of Treasury to fax my business' confidential tax information to the fax number included. I
recognize that faxing is not a secure means of transmission and I assume all risks involved in this transmission method.
Signature
31. Printed Name
32. Title
33. Date
Signature
34. Printed Name
35. Title
36. Date
Signature
37. Printed Name
38. Title
39. Date
Before submitting your application, complete all items on this checklist.
Complete every line of the application. Insert N/A if a line does not pertain to your business.
An applicant for a wholesaler or unclassified acquirer license must include its most current financial statement including balance
sheet. An application will not be processed without financial statements. A balance sheet is a summary of the company assets
and liabilities. A financial statement is a statement of profit and loss.
Lease Agreements must be submitted for all locations that are leased. The lease agreement must be valid for the entire license
year of July 1st through June 30th.
If you are renewing your license, confirm that all returns have been submitted. An application will not be processed until the
outstanding tax returns have been received.
Confirm that all assessments have been paid in full. This includes all other taxes such as sales, use and
withholding.
Sign the application.
Enclose the application fee.
Mail the original application with the proper fee to the address below and make a copy for your records.
Michigan Department of Treasury
Special Taxes Division
P.O. Box 30474
Lansing, MI 48909-7974
Questions: Call the Tobacco Taxes Unit at (517) 636-4630.
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