Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application Page 3
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4Purchase other tobacco products from suppliers that are not Missouri licensed wholesalers. Please list all suppliers, including names, complete addresses, and telephone
numbers. Attach additional sheet if necessary.
Reset This Section
Supplier Name
Address
Telephone Number
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Operate retail stores where cigarettes and other tobacco products are sold. Please list all company names and locations, including sales tax identification number of
each location. Attach additional sheet if necessary.
Reset Retail Stores Sold Together
Company Name
Address
MO Tax I.D. Number
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
Own, operate, and service cigarette vending machines and humidors. Please list all vending machines or humidors, including name, address of each location, and sales tax
identification number. Attach additional sheet if necessary.
Reset Cigarette Vending
Retail Store Name
Address
MO Tax I.D. Number
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
Place other tobacco products in retail locations on consignment. Please list all, including name and address of each location and a sample copy of the contract between you and
the retailer. Attach additional sheet if necessary.
Reset Other Tobacco Products
Retail Store Name
Address
Buy and/or sell tobacco products on the Internet. Web site address:______
________________________________________________________________________________________
Buy and/or sell tobacco products by telephone sales.
Buy and/or sell tobacco products by catalog sales. Please attach a copy of your catalog.
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DOR-2175 (07-2011)
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