Form 2175 - Missouri Cigarette/other Tobacco Products Tax License Application Page 4

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SECTION 8 - CIGARETTE TAX STAMPING INFORMATION

Indicate your stamping method:

Meyercord Stamping Machine

Machine Number: __________________________

Heat Applied

Other __________________________________________

SECTION 9 - CIGARETTE TAX STAMP PURCHASING INFORMATION

Indicate your shipping method for cigarette tax stamps (Wholesaler is responsible for shipping costs):

UPS Number:____________________________________

FedEx Number:___________________________________

Check the appropriate box indicating how you wish to purchase cigarette tax stamps:

Cash Basis (No Bond Required)

Credit Basis*

Cash and Credit Basis*

* Must post bond for amount of credit desired.

SECTION 10 - BOND INFORMATION

Check the appropriate box indicating which type of bond you will be acquiring:

Cigarette Wholesaler Bond (required only for wholesalers purchasing cigarette tax stamps on credit)

Letter of Credit

Surety Bond

Cash Bond

Other Tobacco Products Bond*

Letter of Credit

Surety Bond

Cash Bond

* Other Tobacco Products licensees are required to maintain a bond in the amount of three times the average tax liability, with a $500 minimum. Upon review, if the Director of Revenue

deems your current bond insufficient to cover the liability, the bond requirement will be adjusted to a satisfactory level in accordance with your current tax liability.

SECTION 11 - REPORTING FORMS - ALL APPLICANTS MUST COMPLETE THIS SECTION

Reset Section 11

If you are licensed for cigarette or other tobacco products in other states, please list the state and all license numbers.

State

License Number

State

License Number

How do you want to receive reporting forms and updates? (Check one)

I will download from the internet.

Please mail one set of forms on a yearly basis.

Form 5298 (Registration for Electronic Notification of Changes in the Missouri Tobacco Directory) attached.

Missouri Secretary of State Certificate of Organization attached. (Required unless business is owned by a sole proprietor)

SECTION 12 - SIGNATURE

The application must be signed by the owner if the business is a sole proprietorship; partner, if the business is a partnership; reported officer, if the business is a corporation or by

a member if the business is a L.L.C. as reported on this application. The signature MUST be of the owner, partner, or officer as reported on this application. I declare that the above

information and any attachments are true, complete, and correct. I further certify under the penalty of perjury that I will comply fully with sections 196.1020 through 196.1035, RSMo.

SIGNATURE

TITLE

DATE

___ ___ / ___ ___ / ___ ___

PLEASE TYPE OR PRINT NAME

DOR-2175 (07-2011)