Form 150-105-001 - Application For Distributor'S License - 2001 Page 2
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1
2ADDITIONAL INFORMATION REQUIRED FROM APPLICANTS
What is the nature of your business that requires an Oregon license?
In what area (cities) do you plan to distribute in Oregon?
List the name, address and phone number of your suppliers:
(attach additional pages as necessary)
1.
4.
2.
5.
3.
6.
List each manufacturer’s name and the warehouse address from which you receive your supply:
(attach additional pages as necessary)
Manufacturer’s Name
Warehouse Address
City, State, ZIP Code
Identify other licenses issued to you for cigarette and tobacco products for any other state:
(attach additional pages as necessary)
State
Type of License
(i.e., cigarette; tobacco products)
Will you use Oregon cigarette tax stamps on products that you distribute?
Yes
No
If yes, explain how and where you will affix
the stamps for distribution.
Does the business being conducted violate any Oregon law?
Yes
No
Have you (applicant) or any other person listed on this application, ever been denied a permit, license, or other authorization to engage
in any business to manufacture, export, or import tobacco products by any government agency (federal, state, local, or foreign), or had
such permit, license, or other authorization revoked, suspended, or otherwise terminated?
Yes
No
If yes, you must explain.
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