Form Ap-193 - Texas Application For Retailer - Cigarette, Cigar, And/or Tobacco Products Tax Permit Page 2

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AP-193
TEXAS APPLICATION FOR RETAILER
(Rev.4-00/5)
CIGARETTE, CIGAR, AND/OR TOBACCO
PRODUCTS TAX PERMIT
Page 2
NOTE: Where space indicators are shown, please enter only one letter or number in each space and skip one space between words.
Legal name of owner (Same as Item 2)
7. Will you sell or store tobacco at the location where the records will be kept? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Yes
No
8. Business location name
•
9. Is this location inside the city limits? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Yes
No
10. Business location address (Street & no. - DO NOT use a P.O. Box or rural route and box no.)
•
City
State
ZIP code
•
•
•
County
11. Enter the daytime phone
number of the person primarily
•
responsible for this business.
12. Will you be selling cigarettes, cigars, and/or tobacco products from this business location? _ _ _ _ _ _ _ _ _
Yes
No
13. Is this a commercial business location? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Yes
No
14. Does this business location include a humidor? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Yes
No
Month
Day
Year
15. What is the first business date that this business location
will be making sales of cigarettes, cigars, and/or tobacco products? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
16. Will you be selling cigarettes, cigars, and/or tobacco products from vending machines that you own? _ _ _
Yes
No
17. If you do not own the vending machines, list the machine owner's name and mailing address:
Name
Mailing address (Street & no., P.O. box or rural route and box no.)
City
State
ZIP code
18. Do you own the cigarettes, cigars, and/or tobacco products displayed for sale in the vending machines? _ _ _
Yes
No
19. Enter the following information for each vending machine (Use additional sheets, if necessary.) :
MACHINE MAKE
MODEL
SERIAL NUMBER
INVENTORY NUMBER
IN-SERVICE DATE
PHYSICAL LOCATION OF MACHINE:
PHYSICAL LOCATION OF MACHINE:
PHYSICAL LOCATION OF MACHINE:
PHYSICAL LOCATION OF MACHINE:
20. Where will business records for machines be maintained? (Use street address or directions, city, state, and ZIP code - NOT P.O. Box, rural route or public storage.)
– MUST BE A COMMERCIAL LOCATION.
21. Will you sell or store tobacco at the location where the records will be kept? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Yes
No
The sole owner, all general partners, corporation president, vice-president, secretary or treasurer, or an
Date of application (Mo., day, year)
authorized representative must sign this application. Representative must submit a written power of attorney
with application. (Attach additional sheets, if necessary.)
22. I (We) declare that the information in this document and any attachments is true and correct to the best of my (our) knowledge and belief.
Type or print name and title of sole owner, partner or officer
Sole owner, partner or officer
sign
here
Type or print name and title of partner or officer
Partner or officer
sign
here
Type or print name and title of partner or officer
Partner or officer
sign
here
YOUR PERMIT MUST BE PROMINENTLY DISPLAYED IN YOUR PLACE OF BUSINESS.
ALL INFORMATION PROVIDED ON THIS FORM MAY BE DISCLOSED TO THE PUBLIC, UPON REQUEST, UNDER THE
TEXAS PUBLIC INFORMATION ACT, GOVERNMENT CODE, CHAPTER 552.
To expedite the receipt of your permit, complete this application and mail to:
Make check payable to:
COMPTROLLER OF PUBLIC ACCOUNTS
111 E. 17th Street
STATE COMPTROLLER
Austin, TX 78774-0100

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