Form Crf-008 - Tobacco License Application

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,
CRF-008 (Rev 05/04)
TOBACCO LICENSE APPLICATION
Georgia
Department
of Revenue
Registration Unit
(Read
Instructions
Before Completing)
P O. Box 49512
Atlanta, Georgia 30359-1512
404-417-4490
FOR OFFICE
1
STATE TAXPAYER
IDENTIFIER:
USE ONLY
2
LEGAL BUSINESS
NAME:
I I I I
3
TYPE OF LICENSE: (Check One)
D
WHOLESALE
D
RETAIL
D
MANUFACTURER
D
IMPORTER
I I I I I I I
4
WHEN DID OR WILL YOU START
SELLING TOBACCO
PRODUCTS?
5
KIND OF BUSINESS
ENGAGED
IN
IF YOU ARE APPLYING
FOR A WHOLESALE
UCENSE,
COMPLETE
THE REMAINING
QUESTIONS
6
WHAT WERE YOUR GROSS SALES OF TAXABLE
CIGARS, CIGARETTES
AND LOOSE OR SMOKELESS
$
TOBACCO
FOR THE PAST YEAR?
7
DO YOU NOW OR DO YOU PLAN TO AFFIX
THE CIGARETTE
EXCISE STAMP?
DYES
D
NO
8
DOES THE PERSON MAKING APPLICATION
HOLD A RETAIL CIGAR, CIGARETTE
OR LOOSE AND
SMOKELESS
TOBACCO
LICENSE?
DYES
D
NO
(If "YES", list name of retail business and retail license number)
9
STI NUMBER
RETAIL BUSINESS
NAME
TOBACCO
LICENSE NUMBER
10
LIST ALL THE EMPLOYEES OF YOUR BUSINESS AND INDICATE THEIR POSITION AND SOCIAL SECURITY NUMBER
NAME
TITLE
SOCIAL
SECURITY
NO.
THIS APPLICATION
HAS BEEN EXAMINED
BY ME, AND TO THE BEST OF MY KNOWLEDGE
IS TRUE AND
CORRECT.
SIGNATURE
TITLE
DATE
(MUST
BE SIGNED
BY OWNER,
PARTNER,
OR AUTHROIZED
OFFICER
OF CORPORATION
- STAMPED
SIGNATURE
NOT ACCEPTABLE)
FOR OFFICE USE ONLY
TOTAL FEE PAID
$
D
REGISTRATION
STATUS
[~
REGISTRATION
REASON
STATE LICENSE NUMBER
ISSUE DATE
Print
Clear
CRF-008 (Rev.11/08)
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