Form Ttb F 5200.3 - Application For A Permit As A Manufacturer Of Tobacco - Department Of The Treasury Page 3

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a. Full legal name

b. Date and place of birth

c. Social security or employer identification number

e. Citizen or business of United States

f. Other names used (maiden name, nicknames, etc.)

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.)

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

13. Have you or any person listed in items 10 or 11 been denied a permit, license, or other authorization to engage in any business by any govern-

ment agency (Federal, State, local, or foreign) or had such permit, license, or other authorization been revoked, suspended, or otherwise terminated?

Yes and I have attached the details of each occurrence to this application.

14. Have you or any person listed in items 10 or 11 been arrested for, charged with, or convicted of, any crime under Federal, State, or foreign laws?

(You do not have to include arrests, charges, or convictions for operating a motor vehicle that are not felonies under Federal or State law.)

Yes and I have attached the details of each occurrence to this application.

15. I declare that I have read the instructions for this form. I understand that I may need to file other TTB forms before TTB may act on this

application.

I understand that this application includes the information that I have attached to this form or incorporated by reference.

I understand that an appropriate TTB officer may require additional information to determine if I am entitled to the permit for which I am

applying.

Before TTB makes its final decision about this application, I will immediately write to the TTB supervisor of the office listed in instruction B if any

information for this application changes.

Under penalties of perjury, I have examined this application, and to the best of my knowledge and belief, this application, including any

attachments, is true, correct, and complete.

a. Signature

b. Title

c. Date

d. E-mail address (optional)

e. Business telephone number

How do I file this form? Send this form to the TTB National Revenue Center, 550 Main St, Ste 8002,Cincinnati, OH 45202-5215.

TTB F 5200.3 (10/2006)

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