Form Dtf-719-Mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products - New York State Department Of Taxation And Finance Page 4

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Part B - Vending machine registration certificates (continued)

Business name

Physical address where vending machine is located

Serial number of each

(report each machine separately in column C)

vending machine

Number of vending machine registration certificates from previous page (if last page, include totals from

additional copies, if attached). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total number of vending machine registration certificates required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Enter this total on page 1, line 2, column A, as applicable.

DTF-719-C-MN (6/11) (back)