Form Dp-31 - Application For Tobacco License - State Of New Hampshire
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1FORM
FOR OFFICE USE ONLY
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
DP-31
APPLICATION FOR TOBACCO LICENSE
LIC #
065
ISSUED BY
STATE OF NEW HAMPSHIRE
DATE
DEPARTMENT OF REVENUE ADMINISTRATION
PO BOX 637
CHECK APPROPRIATE BLOCK(S):
(SEE DEFINITIONS ON BACK)
CONCORD, NEW HAMPSHIRE 03302-0637
RETAILER (Check A or B)
$
A.
B.
A
LICENSE RENEWAL
NEW LICENSE
OVER THE COUNTER SALES.......Fee is $10.00 For Each Location
B
VENDING MACHINE SALES
1. TRADE NAME
$
Number of Machines to be Licensed _____ at $10.00 each
$
Number of Locations __________ at $10.00 each location
2. OWNER
$
VENDING MACHINE OPERATOR Fee is $70.00
3. NH BUSINESS
Any person operating one or more tobacco vending machines on
ADDRESS
property or premises OTHER THAN HIS OWN needs this license,
in addition to a retail vending machine license for each machine.
$
MANUFACTURER.......................................................Fee is $100.00
4. BUSINESS PHONE
$
SUB-JOBBER.............................................................Fee is $150.00
5. MAILING ADDRESS IF
$
WHOLESALER...........................................................Fee is $250.00
DIFFERENT THAN #3
$
SAMPLER.....................................................................Fee is $10.00
TOTAL AMOUNT ENCLOSED
$
6. IF NEW OWNER
PLEASE INDICATE:
FEE MUST ACCOMPANY THE APPLICATION
NAME OF FORMER OWNER
AND
DATE OF PURCHASE
MAKE CHECKS PAYABLE TO STATE OF NEW HAMPSHIRE
FOR OFFICE USE
7. TYPE OF ORGANIZATION & IDENTIFICATION NUMBER
1
Proprietorship
SOCIAL SECURITY NUMBER
2
Corporation
FEDERAL EMPLOYER INDENTIFICATION NUMBER
3
Partnership
8.
SIGNATURE
DATE
DP-31
BE SURE TO READ INFORMATION ON THE REVERSE SIDE
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