Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application Page 2

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SECTION 4 - OWNERSHIP INFORMATION - IDENTIFY OWNERS, OFFICERS, PARTNERS, MEMBERS
(ATTACH LIST IF ADDITIONAL SPACE IS REQUIRED.)
Reset Section 4
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___
HOME ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EFFECTIVE DATE OF TITLE
__ __ __ __ __
___ ___ / ___ ___ / ___ ___
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___
HOME ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EFFECTIVE DATE OF TITLE
__ __ __ __ __
___ ___ / ___ ___ / ___ ___
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NUMBER
BIRTHDATE
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___
HOME ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EFFECTIVE DATE OF TITLE
__ __ __ __ __
___ ___ / ___ ___ / ___ ___
Reset Section 5
SECTION 5 - PREVIOUS OWNER INFORMATION
NAME OF PREVIOUS OWNER
NAME OF PREVIOUS BUSINESS
PREVIOUS LICENSE NUMBER
DATE BUSINESS CLOSED
__ __ / __ __ / __ __
PREVIOUS BUSINESS ADDRESS
CITY
STATE
ZIP CODE
COUNTY
__ __ __ __ __
SECTION 6 - NAMES OF ANY PERSONS ASSOCIATED WITH THIS COMPANY WHO PRESENTLY OR PREVIOUSLY OWNED, OPERATED,
OR MANAGED ANOTHER CIGARETTE OR TOBACCO COMPANY. (ATTACH A LIST IF ADDITIONAL SPACE REQUIRED.)
COMPANY NAME
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
HOME ADDRESS
CITY
STATE
ZIP CODE
LICENSE NUMBERS
__ __ __ __ __
SOCIAL SECURITY NUMBER
BIRTHDATE
___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
COMPANY NAME
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
HOME ADDRESS
CITY
STATE
ZIP CODE
LICENSE NUMBERS
__ __ __ __ __
SOCIAL SECURITY NUMBER
BIRTHDATE
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___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___ ___
SECTION 7 - BUSINESS ACTIVITIES (DESCRIBE ACTIVITY AND CHECK ALL BOXES THAT APPLY TO YOUR BUSINESS.)
RETAIL ____________%
WHOLESALE _____________%
MANUFACTURER _____________%
OTHER _____________%
Describe the primary business activity:
_______________________________________________________________________________________________________________________________
Purchase all products (unstamped, cigarettes and other tobacco products) direct from the manufacturer. Please list all manufacturers, including names, complete addresses,
and telephone numbers. Attach letters of recommendation from major manufacturers for cigarette licenses. Attach additional sheet if necessary.
Manufacturer Name
Address
Telephone Number
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Purchase tax-paid or stamped product from Missouri licensed wholesalers. Please list all licensed wholesaler names and license numbers. Attach additional sheet if necessary.
Missouri Licensed Wholesaler Name
License Number
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2
DOR-2175 (07-2011)

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