Form Dbpr Abt-6005 - Application For Tobacco Products Wholesale Dealer (Page 5 of 7) in pdf

Form Dbpr Abt-6005 - Application For Tobacco Products Wholesale Dealer Page 5

SECTION 4 – DISCLOSURE OF INTERESTED PARTIES

FOR CORPORATIONS, LIMITED PARTNERSHIPS OR OTHER LEGAL ENTITIES

Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or

revocation of your license.

Trade Name (D/B/A)

1. List below the names, titles and percentage of stock held for all officers, managing members and general

partners of the corporation or other legal entity for which this license or permit is being sought. Attach

extra sheets if necessary.

Title/Position

Name

Stock %

President

Vice President

Secretary

Treasurer

Managing Member(s)

General Partner(s)

Direct Interest

Indirect Interest

2. Does anyone other than the individuals listed above own stock in the applicant entity?

Yes

If yes, please list below.

Title/Position

Name

Stock %

3. Right of Occupancy

a. Does the applicant have a legal right of occupancy to the premises?

Yes

b. Does the applicant own the property?

Yes

c. Does the applicant rent, lease or sublease the property?

Yes

d. If the answer to the previous question is yes, is anyone else listed as leasee or

Yes

subleasee who is not on the application?

Form Dbpr Abt-6005 - Application For Tobacco Products Wholesale Dealer Page 5