Form Dbpr Abt-6024 - Application For Cigarette/tobacco Wholesaler, Tobacco Exporter, Or Cigarette Distributing Agent Page 8
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9SECTION 9 - CURRENT LICENSEE UPDATE DATA SHEET
This section is to be completed for all current tobacco license holders listed on the application to ensure the
most up to date information is captured.
Trade Name (D/B/A)
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
8
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Parent category: Legal