Form Dtf-719-Mn - Renewal Application For Registration Of Retail Dealers And Vedning Machines For Sales Of Cigarettes And Tobacco Products Page 2

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Part A - Certificates of registration for retail operations ($100 each)
In column A, indicate whether you are currently making retail sales of cigarettes or tobacco products. In columns B
and C, list the business name and address for each business location at which you are making retail sales
of cigarettes or tobacco products. For business name, enter trade name, DBA (doing business as) name, or assumed
name if different from your legal name. If you sell cigarettes or tobacco products from your main physical address,
list it first . Attach additional sheets if necessary.
A
B
C
D
Seq. Y=yes
Business address
Date to begin
Business name
No.
N=no
selling cig./tob.
products
Total number of certificates of registration required . . . .
Enter this total on page 1, line 4,
column A
DTF-719-MN (6/06) (back)

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