Form Boe-400-Ld - Application For Retailer'S Cigarette And Tobacco Products License Page 6

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BOE-400-LD (S4) REV. 2 (7-07)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
CALIFORNIA CIGARETTE AND TOBACCO PRODUCTS LICENSING ACT OF 2003
SCHEDULE A - DISTRIBUTOR'S BUSINESS LOCATIONS
(Instructions are in the application under No. 5 on page S3F.)
ACCOUNT NUMBER:
OWNER NAME:
PERIOD:
A
B
C
D
E
BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE
E-MAIL ADDRESS
ENTER 1
(must provide if not listed below)
NUMBER
IF CIGARETTE OR
(including
TOBACCO PRODUCTS
area code)
WILL BE SOLD
AT THIS LOCATION
TOTAL NUMBER OF LICENSES REQUIRED:
CLEAR
PRINT

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