Form Ttb F 5200.3 - Application For A Permit As A Manufacturer Of Tobacco - Department Of The Treasury Page 2

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a. Full Legal Name
b. Title and position in my business
c. Percent (%) of voting stock or interest held in my business as a
d. Dollar amount of investment in my business as a manufacturer of
manufacturer of tobacco products or an export warehouse proprietor.
tobacco products or as an export warehouse proprietor.
Do NOT include stock held by a corporation to determine the percent
Anticipated:
Current:
of voting stock.
$
$
f. Reason for, or source of, investment. For example: savings, loan,
e. Name and address of the person(s) from whom the investment
profits from other business, or gift
comes
a. Full Legal Name
b. Title and position in my business
c. Percent (%) of voting stock or interest held in my business as a
d. Dollar amount of investment in my business as a manufacturer of
manufacturer of tobacco products or an export warehouse proprietor.
tobacco products or as an export warehouse proprietor
Do NOT include stock held by a corporation to determine the percent
Anticipated:
Current:
of voting stock.
$
$
f. Reason for, or source of, investment. For example: savings, loan,
e. Name and address of the person(s) from whom the investment
profits from other business, or gift
comes
11.
I have identified for item 10 the person(s) having actual or legal control over my business (Read instructions N and P) .
OR
I have identified the person(s) having actual or legal control over my business (Read instructions N and P) BY attaching to this application
the information as required by item 10 WITH a statement on how actual or legal control is exercised.
12.
I have provided the information shown in the tables below for each person listed for items 10 and 11.
OR
I have NOT provided this information because of the following reason:
a. Full legal name
b. Date and place of birth
c. Social security or employer identification number
f. Other names used (maiden name, nicknames, etc.)
d.
e. Citizen or business of United States?
Male
Yes
Female
No (state country)
g. Residence(s), or place(s) of business, over the last five years
a. Full legal name
b. Date and place of birth
c. Social security or employer identification number
f. Other names used (maiden name, nicknames, etc.)
d.
e. Citizen or business of United States?
Male
Yes
Female
No (state country)
g. Residence(s), or place(s) of business, over the last five years
TTB F 5200.3 (10/2006)
Page 2 of 3

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