Form Ctx-Aw - Application For A Wholesale Cigarette License Or License To Operate Cigarette Vending Machines - New York Department Of Finance Page 2

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CTX-AW, Page 2
(ATTACH ADDITIONAL SHEETS IF NEEDED TO COMPLETE REPORT)
PLEASE LIST ALL VEHICLES THAT YOU UTILIZE TO TRANSPORT CIGARETTES
Make/Year
License Plate #
State
Registered Owner
Make/Year
License Plate #
State
Registered Owner
12.
Make/Year
License Plate #
State
Registered Owner
Make/Year
License Plate #
State
Registered Owner
PLEASE LIST THE NAMES AND ADDRESSES OF ALL CIGARETTE SALESMEN OR ROUTEMEN REPRESENTING YOU
Name/Home Address
Name/Home Address
Name/Home Address
Name/Home Address
13.
Name/Home Address
Name/Home Address
Name/Home Address
Name/Home Address
PLEASE LIST BELOW LOCATIONS OF ALL VENDING MACHINES
(Use Form CTX-A34a for additional space or attach separate schedule.)
Name
Type of Business
Address
14.
Name
Type of Business
Address
(If "no," please provide
I AFFIRM THAT THIS BUSINESS FILED ALL REQUIRED NEW YORK
details.)
15.
CITY AND NEW YORK STATE TAX RETURNS AND PAID ALL NEW
Yes
No
YORK CITY AND NEW YORK STATE TAX LIABILITIES.
In NYC
Outside NYC
NUMBER OF CIGARETTE VENDING MACHINES
16.
ST
AS OF FEBRUARY 1
OF FILING YEAR
Bank References
17.
THE UNDERSIGNED HEREBY CERTIFIES THAT THE ANSWERS TO THE ABOVE QUESTIONS ARE CORRECT TO THE BEST OF
HIS KNOWLEDGE AND BELIEF.
Business Name
Applicant Name
Applicant's Signature
Applicant's Title
Date
ANY INCORRECT ANSWERS TO THE ABOVE QUESTIONS RENDER A LICENSE ISSUED UNDER THIS APPLICATION SUBJECT
TO REVOCATION PURSUANT TO TITLE 11, CHAPTER 13 of the NYC ADMINISTRATIVE CODE FOR THE LICENSE YEAR
INDICATED ON THE FRONT.
NYC Dept. of Finance
Submit check with application made payable to NYC Department of Finance and mail to:
CTX Enforcement Unit
th
345 Adams Street, 13
Floor
Brooklyn, NY 11201
Visit us on the World Wide Web at

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