Form Cm-100 - License Application - State Of New Jersey - Division Of Taxation
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1Make Checks Payable To: State of New Jersey
CM-100
State of New Jersey
OFFICIAL USE ONLY
Division of Revenue
(12-08)
D L N
P O Box 252
Trenton, N.J. 08646
PLATE NO.
LICENSE APPLICATION
CHECK ONE BOX
COMPLETE INFORMATION BELOW
ENCLOSE FEE
Motor Fuel Retail Dealers License (three (3) year license) (complete A & B below) . . . . . . . . . . . . . . . . . . . $ 150.00
¨
Motor Fuel Transport License (complete A & C below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
50.00
¨
Cigarette Manufacturer Representative License (one (1) year license) (complete A & D below) . . . . . . . . . . $
5.00
¨
Cigarette Vending Machine License (one (1) year license) (complete A & F below) . . . . . . . . . . . . . . . . . . . $
50.00
¨
Cigarette Retail Dealers Over-the-Counter License (one (1) year license) (complete A & E below) . . . . . . . . $
50.00
¨
IMPORTA N T:A separate application with a separate check must be submitted for each license type.
A. All applicants must complete Part A
Federal Identification Number
___ ___ - ___ ___ ___ ___ ___ ___ ___
Check box if this is a license renewal
¨
Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Name ___________________________________________________________________________________________________
(Corporate, partners, proprietor, representa t i v e )
Trade Name ______________________________________________________________________________________________
Mail Name and Address
Business Location Address
St r e e t
St r e e t
C i t y
St a t e
Zip Code
C i t y
St a t e
Zip Code
TYPE OF OWNERSHIP
Corporation
Proprietorship
Partnership
Representa t i v e
Other ___________________________
¨
¨
¨
¨
¨
Date business began in New Jersey _______ / _______ / _______
Cont a c t Telephone Number (
) _______ - ____________
M o
Day
Yr
OWNER INFORMATION
Name
Ti t l e
S o c i a l S e c u r i t y N o .
Home Address
________________________________
___________________
_______/______/_______
_______________________________________
________________________________
___________________
_______/______/_______
_______________________________________
________________________________
___________________
_______/______/_______
_______________________________________
Complete the information below which pert ains to the specific license.
B.
Motor Fuel Retail Dealers License
Number of pumps . . . . . . . . . __________________________
Capacity in gallons/GASOLINE _________________________
Name of supplier . . . . . . . . . . __________________________
Capacity in gallons/DIESEL ____________________________
Do you sell diesel? . . . . . . . . __________________________
Brand sold . . . . . . . . . . ______________________________
C .
Motor Fuel Transport License (Transport License Plates are not Transferable)
St ate License Plate Number . __________________________
Make of vehicle . . . . . . ______________________________
Vehicle identification number . __________________________
Barge name . . . . . . . . . . . . . __________________________
Year . . . . . . . . . . . . . . . ______________________________
D .
Cigarette Manufacturer Representative License
Name of company you represent _____________________________________________________________________________
E .
Cigarette Retail Over-The-Counter License
Name of company where you purchase your cigarettes ____________________________________________________________
F. Cigarette Vending Machine License
Number of machines you are applying for _________________________ (Enclose a $50.00 fee for each machine)
Name of company where you purchase your cigarettes ____________________________________________________________
You must attach a list with the physical address of each vending machine
Signature ________________________________________________________________
Date __________________________________________
All appropriate information must be completed and the application must have an authorized signature to be processed.
FEE MUST A C C O M PA N Y APPLICATION
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Parent category: Financial