Signature Authorization For Cigarette Stamps Form - Nevada Department Of Taxation

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STATE OF NEVADA
DEPARTMENT OF TAXATION
RENO OFFICE
4600 Kietzke Lane
Web Site:
Building L, Suite 235
Reno, Nevada 89502
1550 E. College Parkway, Suite 115
Phone: (775) 688-1295
Carson City, Nevada 89706-7937
Fax: (775) 688-1303
Phone: (775) 684-2000 Fax: (775) 684-2020
KENNY C. GUINN
In State Toll Free (800) 992-0900
Governor
HENDERSON OFFICE
THOMAS R. SHEETS
LAS VEGAS OFFICE
2550 Paseo Verde Parkway Suite 180
Chair, Nevada Tax Commission
Grant Sawyer Office Building, Suite 1300
Henderson, Nevada 89074
DINO DICIANNO
555 E. Washington Avenue
Phone:(702) 486-2300
Executive Director
Las Vegas, Nevada, 89101
Fax: (702) 486-3377
Phone: (702) 486-2300 Fax: (702) 486-2373
SIGNATURE AUTHORIZATION FOR CIGARETTE STAMPS
Cigarette Wholesale Dealer: __________________________________________________________________
License Number: ___________________________________________________________________________
The person(s) listed below are authorized to purchase and take receipt of Nevada cigarette tax stamps on behalf of
___________________________________________________________________________________________
___________________________________________________________________________________________
This Authorization is effective as of ___________________________ and will continue in force until revised by the
cigarette wholesale dealer or revoked/canceled by the Department of Taxation.
______________________________________________
__________________________________________
Signature and title of person authorized to act on behalf
Type or print
Of the above stated cigarette wholesale dealer
Signature
Name (Type or Print)
1. ___________________________________________
_________________________________________
2. ___________________________________________
_________________________________________
3. ___________________________________________
_________________________________________
4. ___________________________________________
_________________________________________
5. ___________________________________________
_________________________________________
6. ___________________________________________
_________________________________________
7. ___________________________________________
_________________________________________
8. ___________________________________________
_________________________________________
9. ___________________________________________
_________________________________________
10. ___________________________________________
_________________________________________

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