Form Dtf-716 - Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products Page 3

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Page 2 of 2 DTF-716 (6/09)
Part A — Certificates of registration for retail operations
In column A, list the business name and address for each of your business locations registered for sales tax through which you are or
will be making retail sales of cigarettes or tobacco products. For business name, enter trade name, DBA (doing business as) name,
or assumed name if different from your legal name. For each location, mark an X in column B, C, or D to indicate the applicable gross
sales for that location. Attach additional sheets if needed.
Fee scale: Gross sales for business location for period 1/1/08 - 12/31/08
A
B
C
D
Business name and address
$0 - $999,999.99
$1,000,000 - $9,999,999.99
$10,000,000 and over
($1,000 per certificate)
($2,500 per certificate)
($5,000 per certificate)
1.
2.
3.
4.
5.
Totals from additional sheet(s) (if attached) ......................
Column totals
(add number of Xs to totals from additional
sheet(s) in each column and enter result here and on front page,
...............................................
lines 4, 5, and 6, as applicable)
Part B — Vending machine registration certificates
In column A, enter the business name and address where each of your vending machines is located. For each vending machine, mark
an X in column B, C, or D to indicate the applicable gross sales for that vending machine. Attach additional sheets if needed.
Fee scale: Gross sales for vending machine for period 1/1/08 - 12/31/08
A
B
C
D
Business name and address
$0 - $99,999.99
$100,000 - $999,999.99
$1,000,000 and over
(report each machine separately, even if same location)
($250 per certificate)
($625 per certificate)
($1,250 per certificate)
1.
2.
3.
4.
5.
Totals from additional sheet(s) (if attached) ......................
Column totals
(add number of Xs to totals from additional
sheet(s) in each column and enter result here and on front page,
.............................................
lines 8, 9, and 10, as applicable)
Note: Vending machine registration certificates and certificates of registration for 2010 will not be issued before
December 1, 2009.
7160206090094

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