Form Tob: App-Nr - Application For Tobacco Stamping Permit (Non-Resident Wholesaler)
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A
D
R
TOB: APP-NR
LABAMA
EPARTMENT OF
EVENUE
8/07
S
, U
& B
T
D
ALES
SE
USINESS
AX
IVISION
T
T
S
OBACCO
AX
ECTION
P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Application For Tobacco Stamping Permit
(NON-RESIDENT WHOLESALER)
1. Name of business: _________________________________________________________________________________________
2. Type of business:
Corporation
Partnership
Individually Owned
Other ______________________
If not incorporated, give names of owners: ____________________________________________________________________
__________________________________________________________________________________________________________
3. Street address: _____________________________________________________________________________________________
City: ____________________________________________ State: ___________________________ Zip: _____________________
4. FEIN / SSN:
5. Contact person: _______________________________________________ Title: ________________________________________
Telephone number: (
)
–
E-Mail address: ____________________________________________________________________________________________
6. List types of tobacco products you plan to distribute: ___________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
7. The Tobacco Master Settlement Complementary Legislation Act requires wholesalers and distributors to submit reports
to the Alabama Department of Revenue that show the total number of cigarettes or in the case of roll-your-own, the
equivalent stick count for which the wholesalers and distributors affixed stamps during the previous month or
otherwise paid the tax due. It is unlawful for a wholesaler or distributor to stamp, sell, offer, or possess for sale
cigarettes that are manufactured by a manufacturer that is not in full compliance with this Act. A wholesaler or
distributor can lose their stamping privileges or registration number if they have activity with a manufacturer that is not
in full compliance with the above Act and the NPM Escrow Provisions of Title 6, Chapter 12. Pursuant to the above Act,
the statement below must be signed and notarized in order to complete the application process.
Under penalties of perjury, we hereby certify that we will comply fully with the provisions of the Tobacco Master
Settlement Complementary Legislation Act.
Firm: _____________________________________________________________________________________________________
Signature: _________________________________________________________________________________________________
Type or Print Signature Name: _____________________________________________________________________________ _ _ _
Title: _____________________________________________________________________________________________________
Sworn to and subscribed before me this the _________ day of_____________________, ___________.
Notary Public: _____________________________________________________________________________________________
8. Indicate if you are a
Retailer
Wholesaler or
Manufacturer.
9. Are you a licensed tobacco wholesaler in your state?
Yes
No
Permit number: _____________________________________ Cancellation number: _________________________________
10. Are sales of tobacco products in Alabama made only to licensed retail dealers?
Yes
No
11. How many retail stores selling tobacco products are operated in Alabama under your ownership, supervision, or
management? ______________
OVER
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