Application For Retail Tobacco Products License

Application For Retail Tobacco Products License - 2002 Page 5

STATE OF MAINE

MAINE REVENUE SERVICES

SALES, FUEL & SPECIAL TAX DIVISION

(M.R.S.A., Title 36, Chapter 704.)

APPLICATION for RETAIL TOBACCO PRODUCTS LICENSE

Fee - $25.00

Name and Location of Licensee:

For office use only

License No. _______________

Date Issued ________________

Application is hereby made for a Retail Tobacco Products License.

Business address, if different than indicated above.

________________________________________________________________________

1A.

EIN Number___________________________

If single owner, give name of owner __________________________________________

2A.

SS# ________________________

If partnership, give names and addresses of the several partners

Name_____________________________ Address __________________________________

If corporation, give names and addresses of principal officers or agents within Maine.

Name _____________________________ Address _________________________________

Date of Application _____________Tel.#_____________ ______________________________

Signature of Applicant

THE LICENSE TO BE ISSUED WITH THIS APPLICATION WILL EXPIRE JULY 31, 2002.

Forward this completed application to Maine Revenue Services, Sales, Fuel & Special Tax

Division, PO Box 1064, Augusta, Maine 04333 with a check or money order in the amount of

$25.00 made payable to the STATE TREASURER.

For assistance, please call (207)624-9745

Application For Retail Tobacco Products License - 2002 Page 5