Form 150-105-001 - Application For Distributor'S License - 2001
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1
2APPLICATION FOR
FOR DEPARTMENT OF REVENUE USE ONLY
Date Received
O R E G O N
DISTRIBUTOR’S LICENSE
D E PA R T M E N T
O F R E V E N U E
Cigarette License Number
Date License Issued
Cigarette Distributor
Tobacco Products Distributor
Tobacco License Number
Approved By
• You must also complete the back of this form.
Business Name
Federal Identification Number
Business Identification Number
Physical Street Address
City
County
State
ZIP Code
Mailing Address
City
State
ZIP Code
Phone No.
(if different than above)
(
)
Physical Location of Business Records
City
State
ZIP Code
Phone No.
(
)
Contact Person
Phone No.
FAX No. for Business Records
(
)
(
)
Date Business Started
Type of Organization
Individual
Partnership
Corporation
S Corporation
Other: ____________________
Names of Owners, Partners, Shareholders or Corporation Officers:
Name
Street Address
City, State, ZIP Code
Social Security Number
Nature of Business
Manufacturer
Common carrier
Wholesaler
Within Oregon
Internet sales
Distributor
Retailer
Importer
Outside Oregon
Other: ____________________
Source of Product Supply
Manufacturer’s warehouse stock
Imported direct from outside Oregon
Manufactured in Oregon
From other licensed distributors
Cigarette Tax Stamps
Method of Payment:
Cash
or
Deferred payment
(requires deposit of a bond)
Method of Shipment:
Pick-up
or
Courier: Name__________________________ Courier Account No. _____________
Average number of cigarettes (with Oregon stamps) to be distributed during the year: ______________________
Contact person’s name and phone number: _______________________________________________________________________
Federal Privacy Act Information
Under the general authority of OAR 150-305.100, the Social Security numbers of all company officers of distributorships must be
included in the application for a distributor’s license. This information is to be used primarily by the Oregon Department of Revenue for
identification and compliance purposes in the administration of the Oregon Cigarette Tax Act and the Oregon Tobacco Products Tax
Act. Oregon law permits disclosure of such information to governmental units outside Oregon, which also tax tobacco products and
which grant reciprocal rights.
Signing this application acknowledges awareness of the requirements of the Jenkins Act (Title 15, U.S.C. Sect. 375 et. seq.). This act
requires distributors to file reports with the taxing authority of the state where cigarettes are shipped to persons other than another
licensed distributor. The report must include the total number of cigarettes shipped, and the complete name and address of the person
receiving the cigarettes.
I declare under the penalties for false swearing (ORS 305.990(4)) that I have examined this document and to the best of my
knowledge, it is true, correct, and complete.
Signature
Title
Social Security Number
Date
X
150-105-001 (Rev. 2-01) Web
Additional information on the back
Mail completed application to:
Cigarette/Tobacco Tax
Oregon Department of Revenue
PO Box 14110
Salem OR 97309-0910
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