Form Att-12 - State Tax Application For Tobacco Permit - 2011
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ATT-12 (Rev. 5/11)
STATE TAX APPLICATION
GEORGIA DEPARTMENT OF REVENUE
FOR
ALCOHOL & TOBACCO DIVISION
P O BOX 49728
TOBACCO PERMIT
ATLANTA GA 30359
(Read Instructions Before Completing)
(404) 417-4870
FOR OFFICE
1. STATE TAXPAYER IDENTIFIER (STI)
TOBACCO LICENSE NUMBER
USE ONLY
2. LEGAL BUSINESS NAME
BUSINESS ADDRESS
3. TYPE OF APPLICATION
[ ] MANUFACTURER REPRESENTATIVE LICENSE
[ ] WHOLESALER SALESMAN PERMIT
4. SOCIAL SECURITY NO.
LAST, FIRST, MIDDLE INITIAL OF APPLICANT
DATE OF BIRTH
5. HOME ADDRESS
6. CITY
STATE
ZIP CODE
7. MAILING ADDRESS (If different from home address)
8. BUSINESS PHONE NO.
HOME PHONE NO.
9. HOW LONG HAVE YOU BEEN EMPLOYED BY ABOVE MANUFACTURER / DISTRIBUTOR?
10. PROVIDE YOUR EMPLOYMENT HISTORY FOR THE PAST TEN (10) YEARS
FROM
Month/Yr.
EMPLOYER’S NAME AND ADDRESS
POSITION
11. HAVE YOU EVER BEEN ARRESTED OR HELD BY FEDERAL, STATE, OR ANY OTHER LAW-ENFORCEMENT AUTHORITIES FOR ANY
VIOLATION OF FEDERAL LAW, STATE LAW, COUNTY, OR MUNICIPAL LAW, REGULATION, OR ORDINANCES? (Do not include traffic violations.
All other charges must be included even if they were dismissed)
[ ] YES
[ ] NO
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
___________________________________________________________________________
I DECLARE UNDER PENALTY OF PERJURY THAT THIS STATEMENT HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE IS TRUE,
CORRECT AND COMPLETE.
______________________________________
______________________
Signature
Title
Date
I HEREBY CERTIFY THAT __
__________________________ IS PERSONALLY KNOWN TO ME, THAT HE SIGNED HIS NAME TO THE
FOREGOING APPLICATION AFTER STATING TO ME THAT HE KNEW AND UNDERSTOOD ALL STATEMENTS AND ANSWERS MADE THEREIN, AND
UNDER OATH ACTUALLY ADMINISTERED BY ME, HAS SWORN THAT SAID STATEMENTS AND ANSWERS ARE TRUE.
THIS__________ DAY OF ___________________________, _________________
_____________________________________
Notary Public
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