Form Tob 555 - Application For Tobacco License
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TOB
APPLICATION FOR TOBACCO LICENSE
555
Each person engaged in the business of selling, distributing, or handling tobacco products in this state is required to file an application with
the Department of Revenue on or before May 31 of each year for a license to engage in such business. Any person commencing business
subsequent to May 31, shall apply for such license prior to or concurrent with the commencement of business. The license will expire on May
31 of each year.
COMPLETE THIS FORM AND RETURN IT WITH YOUR REMITTANCE. ALL QUESTIONS MUST BE ANSWERED COMPLETELY FOR YOUR
REMITTANCE TO BE PROPERLY CREDITED. This license may be revoked upon the failure to pay a tax or taxes, or for the violation of any rule
or regulation that the commissioner has authorized (including the sale of illegal cigarettes). For additional information regarding this
application you may call Taxpayer and Vehicle Services between 8:00 a.m. and 4:30 p.m. (CT), Monday through Friday, holidays excepted.
Please see the back of this notice for our local offices and phone numbers.
BUSINESS MAILING ADDRESS
BUSINESS NAME AND EXACT LOCATION
STREET OR ROUTE, P.O. BOX #
NAME (GIVE TRADE NAME AT THIS LOCATION)
CITY
STATE
ZIP CODE
STREET, HIGHWAY, COMMUNITY (DO NOT USE P.O. BOX #)
TN
CITY
COUNTY
STATE
ZIP CODE
BUSINESS TELEPHONE NUMBER
FAX NUMBER
TN
Area Code (
)
Area Code (
)
BUSINESS E-MAIL ADDRESS
EFFECTIVE DATE
FEIN/SSN
CONTACT E-MAIL ADDRESS
CONTACT PERSON
FAX NUMBER
PHONE NUMBER
Area Code (
)
Area Code (
)
Nature of Applicant Business ___________________________________________________________________ .
Check applicable block: Participating Manufacturer ________
Non-Participating Manufacturer ________
Applicant has interest in firm(s) selling retail tobacco products.
Yes
No
Applicant has warehousing facilities for tobacco manufacturers.
Yes
No
Applicant has wholesale facilities at a permanent location.
Yes
No
Applicant will purchase unstamped cigarettes.
Yes
No
Applicant will purchase untaxed tobacco products (not cigarettes).
Yes
No
Applicant will export and/or sell to tax exempt agencies unstamped cigarettes;
Yes
No
requests permission for 30 day supply of ________ packs.
Applicant will purchase stamped cigarettes.
Yes
No
Applicant is aware of Tennessee's "complementary legislation", T.C.A. Section 67-4-2601 et seq.
Yes
No
Applicant intends to comply with T.C.A. Section 67-4-2601 et seq.
Yes
No
Has applicant ever had a distribution license denied, revoked, or enjoined by another state.
Yes
No
If yes, please explain _______________________________________________________________________ .
Date you propose to sell cigarettes or began selling cigarettes is _______________________________________ .
Former owner of the business was (if within 3 years) _________________________________________________ .
Former trade name of business was (if within 3 years) _______________________________________________ .
1. Check Type of
A. Distributors or Representatives - $100.00
}
Tobacco License:
B. Wholesale Dealer - stamped cigarettes only -$200.00
C. Wholesale Dealer - other tobacco products - $200.00
NOTE: Please check appro-
D. Manufacturing/Distributor - $200.00
.... (1) $ ___________________
priate box at right and enter
amount on line provided.
E. Manufactuer's Warehouse - $200.00
2. Penalty - Any person failing to apply for a license upon entering business will be
penalized 50% of the license fee for each month or part of a month the failure
continues. Penalty will not exceed the cost of the license. .............................................. (2) $ ___________________
3. Total Remittance Amount ....................................................................................................... (3) $ ___________________
MAKE CHECK PAYABLE TO:
TENNESSEE DEPARTMENT
OF REVENUE
FOR OFFICE USE ONLY
Under penalties of perjury, I declare that the statements in this
application are true and correct to the best of my knowledge
Acct. Number ____________________
and belief. This application applies only to the specified busi-
ness and location listed hereon.
Authorized Signature & Title
INTERNET (7-08)
RV-R0010501
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