Form Ap-175 - Texas Application For Non-Retailer Cigarette, Cigar And/or Tobacco Products Permit - 2013 Page 3

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AP-175-3
(Rev.8-11/13)
Texas Application for Non-Retailer
Cigarette, Cigar and/or
• Type or print.
• Do NOT write in shaded areas.
Tobacco Products Permit
Page 2
NOTE: Where space indicators are shown, enter only one letter or number in each space and skip one space between words.
12. Legal name of owner (same as Item 1)
For Comptroller Use Only
13. Business location name
Job name
MISCAPP
Business location address where cigarettes or cigars/tobacco products are sold, kept for sale or consumption or are otherwise stored
00991
8
8
City
State
ZIP code
Reference No.
County
14. Enter the daytime phone
number of the person primarily
(
)
responsible for the business
15. Is this a commercial business location? .....................................................................................................
YES
NO
16. Is this location inside the city limits? ...........................................................................................................
YES
NO
17. Is this location a customs bonded warehouse? ..........................................................................................
YES
NO
If "YES," please explain.
18. Describe the nature of your business at this location. (Use additional sheets, if necessary.)
month
day
year
19. What is the first business date that this business location will
conduct sales of cigarettes, cigars and/or tobacco products? ...........................................
20. Are you planning to sell cigarettes over the Internet/mail order? ...............................................................
YES
NO
If "YES," please provide your email or Web page address:
NOTE: State law requires all Internet and mail order cigarette sellers planning to deliver cigarettes to a purchaser in Texas
to register their business with the state and collect all applicable state taxes and remit them to the Comptroller's office.
21. Indicate the permit type needed:
Manufacturer
Wholesaler
Distributor
Bonded agent
Importer
22. Indicate the product type:
Cigarette only
Tobacco only
Cigarette and Tobacco
23. Provide your current Dept. of Treasury, Alcohol & Tobacco Tax & Trade Bureau (T.T.B.) permit number(s) for cigarette and/or tobacco products:
24. Will you store unstamped cigarette and/or tax-unpaid tobacco products for which tax is due? ................
YES
NO
If "YES," for whom will you store unstamped cigarettes and/or tax-unpaid tobacco products? (Use additional sheets, if necessary):
25. Indicate how your company will handle sample complimentary products:
Manufacturer will stamp all complimentary cigarettes
Manufacturer will ship to a licensed distributor who will stamp or pay the tax
Manufacturer will pay the tax directly to the State of Texas
Not applicable: Federal military/Native American Reservation sales
for complimentary tobacco products.
26. Will you stamp cigarettes in Texas with another state's stamp? ................................................................
YES
NO
If "YES," please list the other states:
27. Will you sell cigarettes, cigars and/or tobacco products from a motor vehicle? ........................................
YES
NO
If "YES," please complete the following (Use additional sheets or complete Form 69-122, if necessary.):
YEAR
MAKE
MODEL
LICENSE PLATE NO.
STATE
MOTOR VEHICLE ID NUMBER IN-SERVICE DATE
28. If your place of business is a vehicle, where will business records for the vehicle(s) listed above be maintained? (Use street address or directions,
city, state and ZIP code - NOT P.O. Box, rural route or public storage.) — Must be a commercial location.
29. Will you sell or store cigarettes, cigars and/or tobacco products at the location
where the records will be kept? ..................................................................................................................
YES
NO

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