Form 002 - Cigarette Wholesalers & Other Tobacco Products License Application

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Wyoming Department of Revenue
Cigarette Wholesalers & Other Tobacco Products
License Application
An application and license is required for
each business location.
A Ten dollar ($10.00) License Fee must
accompany each application.
Excise Tax Division
Herschler Bldg.
Remittance to be made payable to:
122 W. 25th St.
Department of Revenue
Cheyenne, WY 82002-0110
Phone: (307) 777-5200
Web site:
Department Use Only:
License
No.:___________________________
Date Issued: __________________________
Sales Tax License Number:______________________________
Business Name or DBA::__________________________________________________________________________
Business
Location:________________________________________________________________________________________
Street Address
__________________________________________________________________
(_____) _____-__________
City
State
ZIP
Business Phone
(_____)_____-___________
Mailing Address If
Fax Number
Different From Above:______________________________________________________________________________
Type of Ownership:
Individual
Partnership
Corporation
Association or Other__________
(Specify)
Will you be purchasing unstamped cigarettes directly from a manufacturer?
Yes
No
Will you be purchasing Other Tobacco Products directly from a manufacturer? Yes
No
Date Applicant Started
Doing Business in Wyoming _____/_____/_____
The application shall be signed by:
The Owner, if business is a sole proprietorship.
A Partner, if the business is a partnership.
The President of Vice-President, if the business is a Corporation. If signed by any other officer or person, certified
evidence of authority to sign for and on behalf of the corporation must accompany this application.
Signature:______________________________________________________Title:____________________
ETS Form 002(revised 05/17/02)
Revised 2/99

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