Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application

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FOR OFFICE USE ONLY

MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION DIVISION

LICENSE NUMBER

2175

P.O. BOX 811, JEFFERSON CITY, MO 65105-0811

MISSOURI CIGARETTE/OTHER TOBACCO

(REV. 07-2010)

DATE ISSUED

CHECK NUMBER

PRODUCTS TAX LICENSE APPLICATION

$100.00 FEE IS REQUIRED WITH APPLICATION (MAKE CHECK PAYABLE TO THE “DEPARTMENT OF REVENUE”).

TYPE OF APPLICATION:

REGISTERING FOR:

NEW LICENSE

CIGARETTE WHOLESALER’S LICENSE

OTHER TOBACCO PRODUCTS LICENSE

BOTH

RENEWAL

DATE BUSINESS OPENED

TYPE OF OWNERSHIP

Please indicate your ownership type.

Sole Owner (may include spouse)

Partnership

Limited Partnership – LP Number _____________________________________

Limited Liability Partnership – LLP Number _____________________________

Limited Liability Limited Partnership – LLLP Number _______________________________________________

Government

Not required to register with Missouri Secretary of

Trust

State

Missouri Corporation – Missouri Charter No. ____________________________________

Date Incorporated: _______________

Non-Missouri Corporation – Certificate of Authority No. ___________________________

State of Incorporation and Date Registered in

Missouri _______________________

Limited Liability Company:

Taxed as a Partnership

Taxed as a Sole Owner

Taxed as a Corporation

LLC Number __________________________________

Other ________________________________________________________________________________________________________________

BUSINESS NAME AND PHYSICAL LOCATION

Cigarettes must be stamped and inventory maintained at the physical location. Decals will be shipped to the physical location.

COMPANY NAME

MO TAX I.D. NUMBER

___ ___ ___ ___ ___ ___ ___ ___

DBA NAME

E-MAIL ADDRESS (REQUIRED)

FEDERAL I.D. NUMBER

___ ___ ___ ___ ___ ___ ___ ___ ___

STREET

TELEPHONE NUMBER

(__ __ __) __ __ __ - __ __ __ __

CITY

COUNTY

STATE

ZIP CODE

FAX NUMBER

__ __ __ __ __

(__ __ __) __ __ __ - __ __ __ __

BUSINESS MAILING ADDRESS

RECORD STORAGE ADDRESS

(DO NOT USE PO BOX NUMBER)

STREET, ROUTE OR PO BOX NUMBER

CITY

STREET, HIGHWAY, ROUTE

CITY

STATE

ZIP CODE

COUNTY

STATE

ZIP CODE

COUNTY

__ __ __ __ __

___ ___ ___ ___ ___

CONTACT PERSON

Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax

information can only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant

access to your tax information, you must supply us with a power of attorney giving us the authority to release confidential information to them.

CONTACT PERSON FOR REGISTRATION

TELEPHONE NUMBER

E-MAIL ADDRESS

(__ __ __) __ __ __ - __ __ __ __

CONTACT PERSON FOR REPORTING

TELEPHONE NUMBER

E-MAIL ADDRESS

(__ __ __) __ __ __ - __ __ __ __

BUSINESS ACTIVITIES

(DESCRIBE ACTIVITY AND CHECK ALL BOXES THAT APPLY TO YOUR BUSINESS.)

RETAIL

WHOLESALE

MANUFACTURER

OTHER

Describe the primary business activity:

Purchase all products (unstamped cigarettes and/or other tobacco products) direct from the manufacturer. Attach list of manufacturers, including names, complete

addresses, and telephone numbers. Attach letters of recommendation from major manufacturers for cigarette licenses.

Purchase other tobacco products from suppliers that are not Missouri licensed wholesalers. Attach list of suppliers, including names, complete addresses, and

telephone numbers.

Operate retail stores where cigarettes and/or other tobacco products are sold. Attach list of locations, including tax number of each location.

Own, operate, and/or service cigarette vending machines, and/or humidors. Attach list showing name, address of each location, and sales tax identification number.

Buy and/or sell tobacco products on the Internet. Website Address: ___________________________________________________________________________________

Buy and/or sell tobacco products by telephone sales.

Buy and/or sell tobacco products by catalog sales. Please attach a copy of your catalog.

Place other tobacco products in retail locations on consignment. Attach list showing name and address of each location and a sample copy of contract between you

and the retailer.

This publication is available upon request in alternative accessible format(s).

MO 860-0627 (07-2010)