Form Boe-400-Lr - Application For Retailer'S Cigarette And Tobacco Products License Page 2
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6BOE-400-LR (S2F) REV. 2 (7-07)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
SECTION II: OWNERSHIP INFORMATION
1. PLEASE CHECK TYPE OF OWNERSHIP
Sole Owner
Husband & Wife Co-Partnership
Partnership
Limited Partnership (LP)
Limited Liability Partnership (LLP)
Corporation
Limited Liability Company (LLC)
Registered Domestic Partnership
Other (describe)
2. FULL CORPORATE, LIMITED LIABILITY COMPANY (LLC), OR ORGANIZATION NAME
SECTION III: BUSINESS INFORMATION
1. BUSINESS OR TRADE NAME (DBA if any)
BUSINESS TELEPHONE NUMBER
(
)
2. BUSINESS ADDRESS (do not list PO Box or mailing service)
CITY
STATE
ZIP CODE
ZIP CODE
3. MAILING ADDRESS (if different from No. 2 above)
CITY
STATE
4. LIST ALL OTHER PERMIT OR LICENSE NUMBERS ISSUED TO YOU BY THE BOARD OF EQUALIZATION OR THE DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
5. ADDRESS WHERE BUSINESS RECORDS WILL BE MAINTAINED
BUSINESS E-MAIL ADDRESS
SECTION IV: CERTIFICATION
I affirm that the applicant [including each general partner and each person who has control as defined in California Business
and Professions Code section 22971(p)] has not been convicted of a felony under sections 30473 or 30480 of the Revenue and
Taxation Code and has not violated and will not violate or cause or permit to be violated any of the provisions of the Cigarette
and Tobacco Products Licensing Act of 2003 or any rule of the State Board of Equalization applicable to the applicant
(including each general partner and each person who has control as defined in California Business and Professions Code
section 22971(p)) pertaining to the manufacture, sale, or distribution of cigarettes or tobacco products. The applicant (including
each general partner and each person who has control as defined in California Business and Professions Code section
22971(p)) also agrees to comply with the reporting, payment, recordkeeping, and license display requirements as specified in
the Cigarette and Tobacco Products Licensing Act of 2003 under Division 8.6 (commencing with section 22970) of the
California Business and Professions Code. (If you are unable to affirm this statement, you must provide the Board with a
separate statement containing the nature of any violation or reasons that will prevent you from complying with the requirements
with respect to the statement.)
I certify that all the information provided in this application is complete, true and accurate and I understand that any person who
asserts the truth of any material matter that he or she knows to be false is guilty of a misdemeanor punishable by imprisonment
of up to one year in county jail, or a fine of not more than one thousand dollars ($1,000), or both the fine and imprisonment.
Note: This form must be signed by an owner, partner, corporate officer, LLC member or manager, or by an authorized agent.
For a partnership, attach authorization signed by all general partners; for a corporation, attach corporate resolution;
and for a LLC, attach articles of organization which authorize the individual who signs below to certify this application.
If signed by an authorized agent, a properly completed power of attorney form must be attached to this application.
SIGNATURE
TITLE
NAME (type or print)
DATE
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