Form Tob 555 - Application For Tobacco License Form 2002 printable pdf download

Form Tob 555 - Application For Tobacco License Form 2002

TENNESSEE DEPARTMENT OF REVENUE

500 DEADERICK STREET

ANDREW JACKSON STATE OFFICE BUILDING

NASHVILLE, TN 37242

TOB

APPLICATION FOR TOBACCO LICENSE

555

STREET OR ROUTE, P.O. BOX #

NAME (GIVE TRADE NAME AT THIS LOCATION)

CITY

STATE

ZIP CODE

STREET, HIGHWAY, COMMUNITY (DO NOT USE P.O. BOX #)

CITY

COUNTY

STATE

ZIP CODE

BUSINESS TELEPHONE NUMBER

Area Code (

)

or SSN

FEIN (if required)

}

1. Type of Tobacco License: A.

Distributors - $10.00

Wholesale Dealer & Jobber - $20.00

NOTE: Please check appropriate

box at right and enter amount on

Manufacturing Distributor - $20.00

....... (1) $ __________________

line provided.

Manufactuer's Warehouse - $20.00

2. Penalty - Any person failing to apply for a license upon entering business will be

penalized 50% of the license fee for each month or part of a month the failure

continues. Penalty will not exceed the cost of the license. .............................. (2) $ __________________

3. Total Remittance Amount ........................................................................................ (3) $ __________________

FOR OFFICE USE ONLY

Acct. Number ____________________

Authorized Signature & Title

INTERNET (5-02)

Form Tob 555 - Application For Tobacco License Form 2002