Form Cg-109 - Application For Cigarette Licenses (Page 2 of 2) in pdf

PART II — RETAIL CIGARETTE DEALER'S LICENSE

Enclose a list of names and addresses of each wholesaler from whom you purchase your cigarettes.

Do you make retail sales of motor vehicle fuels or special fuels?

Yes If yes, you must also have a Kansas Motor Fuel

Retailers License. Complete and submit an application, Form MF-53, for each retail location.

Name of company/corporation with whom you have a fuel supply agreement and make retail sale of cigarette and tobacco products:

(e.g., Shell, BP, Phillips 66, Conoco). ________________________________________________________________________

Name of company/corporation with whom you have a retailing agreement and make retail sale of cigarette and tobacco products:

(e.g., Shell, BP, Phillips 66, Conoco) ________________________________________________________________________

PART III — CIGARETTE VENDING MACHINE OPERATOR'S MASTER LICENSE & VENDING

MACHINE PERMITS

PLEASE ENCLOSE CG-83 SEPARATE PAGE LISTING MACHINE BRAND NAME AND SERIAL NUMBER OF EACH

MACHINE.

In addition to the Master License (no fee), a vending machine permit is required for each vending machine in operation. Vending

machine permits are $25.00 each for a two-year calendar period.

Enclose a list of names and addresses of each wholesaler from whom you purchase your cigarettes.

Number of Permits

$25.00

PART IV — WHOLESALE CIGARETTE DEALER'S LICENSE

Each application must be accompanied by a $1,000.00 Wholesale Cigarette Dealer's License Bond. Please complete and return the

enclosed bond form CG-106 with this application. Your salesman must also obtain a wholesale salesman ID card. See Part VI.

For additional information on obtaining a Wholesale Cigarette Dealer's Credit Bond please contact this office by writing to Customer

Relations – Miscellaneous Segment, 915 SW Harrison St., Topeka, Kansas 66625-5000 or call (785) 368-8222 or email

Miscellaneous_Tax@kdor.state.ks.us

PART V — SHOW, CARNIVAL, OR CATERING CIGARETTE DEALER'S LICENSE

PLEASE ENCLOSE SEPARATE PAGE LISTING FOR ALL LOCATIONS WHERE THIS LICENSE IS TO BE USED.

(PERTAINING TO SHOW, CARNIVAL, OR CATERING CIGARETTE DEALER'S LICENSE ONLY)

CAUTION: If this license will be used at places other than listed, advance notice of designated temporary locations where cigarettes

will be sold must be furnished to the Kansas Department of Revenue.

Enclose a list of names and addresses of each wholesaler from whom you purchase your cigarettes.

PART VI — MANUFACTURER SALESMANS CIGARETTE LICENSE OR WHOLESALE SALESMAN

ID CARD

(Enclose a separate sheet with a list of names and addresses if more the one salesman)

Name of Salesperson

Address of Salesperson

Name of Supervisor

Address of Supervisor

SIGNATURE OF SUPERVISOR

Telephone Number

This license is non-transferable but is replaceable upon loss of original license for a $2.00 fee.

Form Cg-109 - Application For Cigarette Licenses Page 2