Form Ctx-Aw - Application For A Wholesale Cigarette License Or License To Operate Cigarette Vending Machines - New York Department Of Finance

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CTX-AW
FEBRUARY 1, 200___TO JANUARY 31, 200___
THE CITY OF NEW YORK
FEE $600.00
APPLICATION FOR A WHOLESALE CIGARETTE LICENSE
Department of Finance
OR LICENSE TO OPERATE CIGARETTE VENDING MACHINES
Audit Division
Name
FOR OFFICIAL USE ONLY
NYC License #
Trade Name
PLACE OF
Location
Street Address
BUSINESS
Date Issued
City/State
Zip
TO BE
Issuer
LICENSED
Telephone
EIN# or SS#
NYS License #
Name or Operator
Trade Name
(if different from above)
1.
Headquarters Street Address
City/State
Zip
2.
PLEASE INDICATE DESIRED
Agent
Sub-
Machine
3.
WHOLESALER’S LICENSE TYPE
Jobber
Jobber
Operator
INDICATE NATURE
Domestic
Out of State
4.
Individual
Partnership
OF OWNERSHIP
Assn or Corp
Assn or Corp
Business Start Date
Incorporation Date
State
NYC Authorization Date
5.
Filing Date
County
IF YOU ARE CONDUCTING BUSINESS UNDER A TRADE NAME,
6.
PLEASE PROVIDE THE TRADE NAME FILING DATE AND
COUNTY CLERK OFFICE WHERE FILED
IF YOU ARE THE SUCCESSOR TO A LICENSED
Name
Address
7.
WHOLESALER, PLEASE PROVIDE THE NAME
AND ADDRESS OF PREDECESSOR
PLEASE PROVIE BELOW THE NAMES, TITLES, AND RESIDENCE ADDRESSES OF ALL
PROPRIETORS, PARTNERS, AND CORPORATE OFFICERS OF YOUR BUSINESS
Name
Title
Address
Phone #
Name
Title
Address
Phone #
8.
Name
Title
Address
Phone #
Name
Title
Address
Phone #
PLEASE PROVIDE NAMES AND ADRESSES FOR FIRMS FROM WHICH YOU PURCHASE CIGARETTES
Name
Address
Name
Address
9.
Name
Address
If "yes," please provide License #
DO YOU HAVE A NEW YORK STATE
10.
No
Yes
CIGARETTE LICENSE?
If "yes," please provide Permit #
ARE YOU A REGISTERED AGENT
11.
No
Yes
IN NEW YORK STATE?

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