Form Boe-400-Eti - Application For Registration - Excise Taxes - 2010 Page 2
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2BOE-400-ETI (BACk) REv. 7 (1-10)
10. NAMES OF BANkS, SAvINGS AND LOANS, CREDIT uNIONS (business/personal)
ADDRESS
ACCOuNT NuMBER
TYPE OF ACCOuNT
11. BuSINESS RECORDS wILL BE MAINTAINED AT
SECTION III: REQUIREMENTS BY CATEGORY
(complete only the category that pertains to the respective license/permit for which you are applying)
CIGARETTE AND TOBACCO PRODUCTS TAX LAw INFORMATION REQUIRED
1. NATuRE OF BuSINESS
a.
Cigarette manufacturer
d.
Cooperative association
h.
Cigarette wholesaler
within California
e.
vending machine operator: Number
i.
Tobacco products distributor
of cigarette machines
Outside California
j.
Tobacco products wholesaler
f.
Common carrier
b.
Cigarette distributor
k.
Tobacco manufacturer
g.
Persons authorized to sell cigarettes
c.
Chain store
within California
on common carriers
Outside California
l.
Tobacco importer
2. SOuRCE OF CIGARETTE/TOBACCO PRODuCTS SuPPLY (check applicable source)
Manufacturers’ warehouse stock in California
Licensed wholesalers
Imported direct from other states
Manufactured in California
Licensed distributors
Imported direct from outside the country
3. NAME OF MAJOR SuPPLIERS
ADDRESS
PRODuCTS PuRCHASED
4. wILL YOu BE STORING ALL OF YOuR CIGARETTE AND TOBACCO PRODuCTS AT YOuR BuSINESS LOCATION?
Yes
No If no, list all of your additional storage locations (attach additional page if necessary)
EMERGENCY TELEPhONE USERS SURChARGE INFORMATION REQUIRED
1. CERTIFICATE OF PuBLIC CONvENIENCE NuMBER (ISSuED BY CA PuBLIC uTILITIES COMMISSION)
u
__________ C
C
2. BILLING AGENT (if applicable)
3. TYPE(S) OF SERvICE OFFERED (check all that apply)
Local exchange
Long distance
Long distance reseller
Cellular
vOIP
Billing Aggregator
Other (please explain)
ENERGY RESOURCES SURChARGE INFORMATION REQUIRED
1. will you be generating and reselling electrical energy?
Yes
No
2. will you be purchasing electrical energy without the State Energy Surcharge from the federal government?
Yes
No
3. Other (please explain)
NATURAL GAS SURChARGE INFORMATION REQUIRED
1. Currently registered with
Public utility Commission (PuC)
Federal Energy Regulatory Commission (FERC)
Number
Number
2. Type of natural gas purchaser
Public utility Gas Corporation
Interstate Pipeline Consumer
SECTION IV: CERTIFICATION
I hereby certify that the statements contained in this application are correct to the best of my knowledge
and belief, and that I am duly authorized to sign this application.
SIGNATuRE
DATE
EMAIL ADDRESS
PRINT NAME AND TITLE
wEBSITE ADDRESS
FOR BOE USE ONLY
furnIshEd to applIcant
REPORTING BASIS
Publication 4
RETURNS/FORMS
Publication 5
RECEIvED BY
SECuRITY
Publication 11
Publication 15
APPROvED BY
Publication 16
REMOTE INPuT DATE
BY
Publication 20
Publication 39
DATE
PERMIT/LICENSE ISSuED
CLEAR
PRINT
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Parent category: Financial