Form Dtf-719-Mn - Renewal Application For Registration Of Retail Dealers And Vedning Machines For Sales Of Cigarettes And Tobacco Products Page 4

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Part B - Vending machine registration certificates ($25 each)
(continued)
A
B
C
Business name
Address where vending machine is located
Serial number of
each vending machine
(report each machine separately in column C)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Number of vending machine registration certificates from previous page . . . .
Total number of vending machine registration certificates required . . . .
Carry forward to next page or, if last page of Part B,
enter this total on page 1, line 5, column A
DTF-719-C-MN (6/06) (back)

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