Application For Distributor'S Cigarette License Form
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1STATE OF MAINE
MAINE REVENUE SERVICES
APPLICATION FOR DISTRIBUTOR’S CIGARETTE LICENSE
(M.R.S.A., Title 36, Chapter 703)
Name and Location of Licensee:
License Number:
Business Name
Mailing Address
Date Issued:
City, State Zip
Application is hereby made for a cigarette Tax License, for use at a wholesale outlet. Cigarettes sold at said
outlet to other persons to be resold at retail.
1.) Physical address of business where tax stamps will be affixed.
_________________________________________________________________________________
2.) Type of Ownership (check one)
□
1a)
Single Owner
(you must complete question 4)
□
1b)
Partnership
(you must complete question 5)
□
1c)
Corporation
(you must complete question 6)
3.) Federal Id ____________________________________________________________________________
4.) If single owner, give name of owner________________________________________________________
4a.) Social Security Number_____________________________________________________
5.) If partnership, give names and addresses of the several partners
NAME_________________________________ ADDRESS_________________________________
NAME_________________________________ ADDRESS_________________________________
6.) If corporation, give names and addresses of principal officers or agents within Maine
NAME_________________________________ ADDRESS_________________________________
NAME_________________________________ ADDRESS_________________________________
Date of Application__________________________ ___________________________________________
Signature of Applicant
A distributor may not sell, offer for sale or display for sale any cigarettes within this State that do not bear stamps
evidencing the payment of the tax imposed by this chapter. The face value of the stamps must be considered as part of
the retail cost of the cigarettes
.
THE LICENSE TO BE ISSUED ON THE APPLICATION WILL EXPIRE JUNE 30, 2005
Mail application to:
MAINE REVENUE SERVICES
SALES, FUEL, & SPECIAL TAXES
PO BOX 1064
AUGUSTA, ME 04332-1064
Questions: contact 207-624-9745
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