Form Dp-31 - Application For Tobacco License
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1
2FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
APPLICATION FOR TOBACCO LICENSE
DP-31
065
FOR DRA USE ONLY
Check A or B as applicable.
A
B
LICENSE RENEWAL
NEW LICENSE
The appropriate fee(s), as listed in Line 10 below, must accompany this form.
FOR INTERNAL USE ONLY
LIC #
ISSUED BY
DATE
PLEASE PRINT OR TYPE
BUSINESS NAME
NAME OF ENTITY
1
2
NH BUSINESS ADDRESS NUMBER & STREET, CITY/TOWN, STATE AND ZIP CODE
BUSINESS PHONE
3
4
MAILING ADDRESS (IF DIFFERENT THAN #3) NUMBER & STREET, CITY/TOWN, STATE AND ZIP CODE
5
FORMER OWNER NAME
PURCHASE DATE
7
6
8 TYPE OF ORGANIZATION & TAX IDENTIFICATION NUMBER CHECK ONE:
2
1
CORPORATION
PROPRIETORSHIP
SOCIAL SECURITY NUMBER
FEDERAL EMPLOYER IDENTIFICATION NUMBER
3
PARTNERSHIP
Proprietorships MUST enter Social Security Number
Corporations and Partnerships, MUST enter Federal Employer
Identification Number
10 LICENSE FEES
9 INDIVIDUAL OWNERS OR OFFICERS
A RETAILER
Over the Counter Sales
$10.00 ................ $
NAME
B Vending Machine Sales
TITLE
SSN
Number of Machines to be Licensed
x $10.00 ea. = .. $
Number of Locations to be Licensed
x $10.00 ea. = .. $
ADDRESS
VENDING MACHINE OPERATOR Fee is $70.00 ........... $
CITY/TOWN, STATE,ZIPCODE
Any person operating one or more tobacco vending machines on property or
premises OTHER THAN HIS OWN needs this license, in addition to a retail
vending machine license for each machine.
NAME
MANUFACTURER
Fee is $100.00 .......................... $
TITLE
SSN
SUB-JOBBER
Fee is $150.00 .......................... $
ADDRESS
WHOLESALER
Fee is $250.00 .......................... $
CITY/TOWN, STATE, ZIP CODE
SAMPLER
Fee is
$10.00 .......................... $
Attach schedule for additional officers.
10 TOTAL AMOUNT ENCLOSED ................. $
FOR DRA USE ONLY
Make check payable to: STATE OF NEW HAMPSHIRE
Enclose, but do not staple or tape your payment to this form.
X
11
SIGNATURE (IN INK)
TITLE
DATE
MAIL
NH DEPT OF REVENUE ADMINISTRATION
PO BOX 637
TO:
DP-31
CONCORD, NEW HAMPSHIRE 03302-0637
Rev. 6/9/06
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