Cigarette Excise Tax Fuson Stamp Purchase Order Form - State Of Nevada
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1NEVADA CIGARETTE EXCISE TAX FUSON STAMP PURCHASE ORDER
Wholesaler:_______________________________________________________ License No:_______________________
Please send the following quantities of Nevada cigarette tax stamps on __________________________________________
(Date)
____________________________via our direct bill account number: __________________________________________
( ) United Parcel Service ( ) Airborne Express ( ) Federal Express ( ) Other ______________________________
All stamp orders will be sent overnight delivery unless otherwise specified. Billing invoice will be sent with the
stamp order.
Name:_____________________________________________________________Phone:___________________________
Address:____________________________________________________________________________________________
City:_____________________________________________State:________________________Zip:__________________
Fuson Stamp (10’s) :
No. Sheets
No. Stamps
Value of Stamps
_________
_________
at $.175 each ____________
Less 3 percent discount _____________
Total amount for 10’s _____________
Fuson Stamp (20’s) :
No. Rolls / Sheets
No. Stamps
Value of Stamps
_________
_________
at $.35 each _____________
Less 3 percent discount _____________
Total amount for 20’s
_____________
Fuson Stamp (25’s) :
No. Rolls
No. Stamps
Value of Stamps
_________
_________
at $.4375 each _____________
Less 3 percent discount _____________
Total amount for 25’s
_____________
Tribal Stamps (No Charge)
TOTAL AMOUNT
No. Rolls
No. Stamps
OF THIS PURCHASE
ORDER
$________________
__________
__________
_____________________________________________________
___________________________
Authorized Signature (Signature on File)
Date
Mail or fax to: Cigarette stamp order Attn: Wendi Skibinski, Department of Taxation, 1550 E. College Parkway
Carson City NV 89706. Fax No. 775-687-5981. Business No. 775-687-6483.
CTSP01
Revised 2-7-00
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