Annual Certification For Manufacturer/importer License Form - 2007 Page 2

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BOE-400-LMR (S1B) REV. 1 (7-07)

SECTION II: CANCELLATION NOTICE (complete this section if you will not be maintaining your Cigarette License)

I am not maintaining my Manufacturer/Importer Cigarette License because (check only one box)

I am no longer in business. Date business discontinued:

Please provide your current daytime telephone number and address:

Other (please explain)

SECTION III: BUSINESS CHANGE (complete this section only if the information preprinted on the front of this application

is incorrect or if there has been a change in the ownership of the business)

1) TYPE OF NEW OWNERSHIP

Sole Owner

Husband & Wife Co-Partnership

Partnership

Limited Partnership (LP)

Limited Liability Partnership (LLP)

Registered Domestic Partnership

Other (describe) __________________

Corporation

Limited Liability Company (LLC)

NEW CORPORATION/LLC NAME AND NUMBER (list names of corporate/LLC officers, members or managers below)

3) NEW OWNER/PARTNER/PRESIDENT NAME

4) NEW BUSINESS OR TRADE NAME/DBA

NEW LOCATION OF BUSINESS (do not use a PO Box or agent's address for location of business)

DAYTIME TELEPHONE NUMBER

(

)

6) NEW MAILING ADDRESS (if different from business location; do not enter agent's address here)

DAYTIME TELEPHONE NUMBER

(

)

8) NEW AGENT/BOOKKEEPER TELEPHONE NUMBER

7) NEW AGENT/BOOKKEEPER NAME

(

)

9) NEW AGENT/BOOKKEEPER MAILING ADDRESS

Please use this address as my mailing address. (check box and attach signed power of attorney form to use agent address for the account mailing address)

SECTION IV: SIGNATURE (this section must be completed, if you made any changes to Section II or III)

SIGNATURE

TITLE

PRINT NAME

TELEPHONE NUMBER

DATE

(

)