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Form Dbpr Abt-6024 - Application For Cigarette/tobacco Wholesaler, Tobacco Exporter, Or Cigarette Distributing Agent Page 6

SECTION 7 – DISCLOSURE OF INTERESTED PARTIES

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, directors, stockholders,

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. If the applicant is a limited partnership or

limited liability company, attach a list of all limited partners and members.

Title/Position

Name

Stock %

President

Vice President

Secretary

Treasurer

Director(s)

Stockholder(s)

Managing Member(s)

General Partner(s)

Bar Manager

(Fraternal Organizations of

National Scope only)

2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person

or entity who has loaned money to the business that is not a traditional lending institution?

Yes

If yes, you must list the person(s) or entity and indicate which of the below applies.

Name

Guarantor

Co-signer

Lender

Interest Rate

(List)

Form Dbpr Abt-6024 - Application For Cigarette/tobacco Wholesaler, Tobacco Exporter, Or Cigarette Distributing Agent Page 6