Form Boe-400-Lrr - Renewal Applicaiton For Retailer'S Cigarette And Tobacco Products License Page 2
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3BOE-400-LRR (S1B) REV. 2 (7-07)
SECTION II: CANCELLATION NOTICE (complete this section if you will not be renewing your Retailer's Cigarette and Tobacco
Products License)
I am no longer in business. Date business discontinued:
Please provide your current daytime telephone number and address:
SECTION III: BUSINESS CHANGE (complete this section only if the information preprinted on the front of this application
or on the enclosed Schedule A, if applicable, is incorrect or if there has been a change in the ownership of the business)
1) TYPE OF NEW OWNERSHIP
Husband & Wife Co-Partnership
Sole Owner
Partnership
Limited Partnership (LP)
Limited Liability Partnership (LLP)
Corporation
Limited Liability Company (LLC)
Registered Domestic Partnership
Other (describe)
NEW CORPORATION/LLC NAME AND NUMBER (list names of corporate/LLC officers, members or managers below)
2)
3) NEW OWNER/PARTNER/PRESIDENT NAME
4) NEW BUSINESS OR TRADE NAME/DBA
5)
NEW LOCATION OF BUSINESS (do not use a PO Box or agent's address for location of business)
DAYTIME TELEPHONE NUMBER
(
)
6) NEW MAILING ADDRESS (if different from business location; do not enter agent's address here)
DAYTIME TELEPHONE NUMBER
(
)
8) NEW AGENT/BOOKKEEPER TELEPHONE NUMBER
7) NEW AGENT/BOOKKEEPER NAME
(
)
9) NEW AGENT/BOOKKEEPER MAILING ADDRESS
Please use this address as my mailing address. (check box and attach signed power of attorney form to use agent's address for the account mailing address)
SECTION IV: SIGNATURE (this section must be completed if you made any changes to Section II or III)
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, record keeping, 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 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
PRINT NAME
PHONE NUMBER
DATE
(
)
If you wish additional information, please contact the State Board of Equalization, Excise Taxes Division,
450 N Street, P.O. Box 942879, Sacramento, CA 94279-0056, Telephone 800-400-7115
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