Agent-Jobbers, Sub-Jobbers, Vending Machine Operators
Attach additional sheets if you need to complete application
DO YOU OR ANYONE ACTING ON YOUR BEHALF OWN, LEASE OR USE ANY VEHICLES TO TRANSPORT CIGARETTES? YES ❏
(If YES, please provide vehicle information for all vehicles used to transport cigarettes. You may use a CTX-A34a Form for additional space or attach
Make & Model
License Plate Number
State of Registration
Registered to Name
DO YOU HAVE ANY CIGARETTE SALESPERSON OR ROUTE-PERSON REPRESENTING YOU?
(If YES, please list full names and addresses of all salespersons or route-persons representing you.)
(FOR VENDING MACHINE OPERATOR ONLY) List below all locations of all vending machines (Use CTX-A34a for additional space or attach a schedule)
Name of Premises (Type of Business)
I affirm that this business filed all required New York City and New York State tax returns and paid all New York City and New York State tax liabilities.
If NO, provide details.
Number of Cigarette Vending Machines located as of February 1, 20 _ _ : In New York City __________
Outside New York City __________
The undersigned Hereby Certifies that the answers to the above questions are correct to the best of his/her knowledge and belief.
Name of Business
Name of Applicant
(PRINT OR TYPE)
Signature of Applicant
ANY INCORRECT ANSWERS TO THE ABOVE QUESTIONS RENDERS A LICENSE ISSUED UNDER THIS APPLICATION SUBJECT TO REVOCATION.
Pursuant to Title 11, Chapter 13 of the Administrative Code for the license year shown on front
Submit check for Application made payable to N.Y.C. Department of Finance and mail to:
CTX - Enforcement Division
345 Adams Street, 13th Floor
Brooklyn NY 11201
Telephone: (718) 403 4318