Application Form For Permit To Transport & Distribute Taxable Tobaccos
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A
D
R
TOB: Rep-A
7/06
LABAMA
EPARTMENT OF
EVENUE
OFFICE USE ONLY
S
, U
, & B
T
D
ALES
SE
USINESS
AX
IVISION
Certification Date _______________
T
T
S
Certification No. _______________
OBACCO
AX
ECTION
Amount Paid
_______________
P. O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Processed By
_______________
Application For Permit To Transport & Distribute Taxable Tobaccos
As Required By Code of Alabama 1975, Section 40-25-19
Name of Applicant:__________________________________________________________________________________________
(Please Print)
Home Address: ______________________________________________________________________________________________
(Street / P.O. Box)
(City / Town)
(State)
(Zip)
Business Address: ____________________________________________________________________________________________
(Street / P.O. Box)
(City / Town)
(State)
(Zip)
Telephone Number: (
)
–
(
)
–
(Work)
(Home)
Name of Tobacco Manufacturer You Are Employed By: ___________________________________________________________
Do you currently distribute tobacco products in Alabama? Yes
No
Do you currently hold a permit to transport and distribute taxable tobaccos? Yes
No
Permit No. ____________
______________
Date you became a representative/agent transporting and distributing tobaccos for this manufacturer:
DESCRIPTION OF APPLICANT
Color of Hair: _________________ Color of Eyes: _________________ Race: ________________________ Sex: _____________
Height: _____________ Weight: _____________ Age: _____________
Make of Vehicle: ______________________________________ Body Type: ___________________________________________
(e.g. Ford, Chevrolet, Toyota, etc.)
(e.g. 2-door, 4-door, van, truck, SUV, etc.)
License Plate Number: _______________________________________ Year: ___________ Color: _________________________
Driver's License Number: ____________________________ Driver’s License Issued By What State: ______________________
VIN Number: _______________________________________________________________________________________________
*Amount Paid With This Application: $______________________________
I hereby certify that the above statements are true and correct.
________________________________________
_______________________________________________________
Applicant’s Signature
Date
*Application must be accompanied by a $50.00 permit fee made payable to Alabama Department of Revenue and mailed to
the address above. All areas of the application must be completed or application will be returned.
PERMIT IS FOR THE PERIOD OCTOBER 1 THROUGH SEPTEMBER 30
State and/or county tax is due on all samples or promotional tobacco products distributed into Alabama. All taxable activity
by the manufacturer’s representatives must be paid and reported on the manufacturer’s monthly tobacco tax return or
report.
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