Form Tob: Reg - Tobacco Products Registration Form - State Of Alabama
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2A
D
R
TOB: REG
LABAMA
EPARTMENT OF
EVENUE
8/03
S
, U
& B
T
D
ALES
SE
USINESS
AX
IVISION
OFFICE USE ONLY
T
T
S
___________
OBACCO
AX
ECTION
Registration No.
P. O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Effective Date ________________
Tobacco Products Registration Form
THIS FORM MUST BE COMPLETED BY DISTRIBUTORS OR CONSUMERS RECEIVING TOBACCO PRODUCTS
FOR WHICH THE STATE AND/OR STATE ADMINISTERED COUNTY TAXES HAVE NOT BEEN PAID.
1. NAME OF COMPANY (INDIVIDUAL’S NAME IF DIRECT CONSUMER OF THE PRODUCT)
2. FEIN OR SOCIAL SECURITY NUMBER
3. ADDRESS
4. CITY
STATE
COUNTY
ZIP
5. CONTACT PERSON
TITLE
6. TELEPHONE NUMBER
(
)
–
7. E-MAIL ADDRESS
8. ADDRESS AT WHICH TOBACCO PRODUCTS ARE RECEIVED IF DIFFERENT FROM ABOVE
9. CITY
STATE
ZIP
10. Type of business (attach name, address, and social security numbers of partners or corporate officers):
Individual
Partnership
Corporation
11. Do you have a privilege license which allows you to sell, offer for sale or store tobacco products?
Yes
No
12. List the types of tobacco you plan to receive for distribution:
______________________________________________________________________________________________
______________________________________________________________________________________________
13. The Tobacco Master Settlement Complementary Legislation Act requires wholesalers and distributors to submit reports
to the Alabama Department of Revenue that show the total number of cigarettes or in the case of roll-your-own, the
equivalent stick count for which the wholesalers and distributors affixed stamps during the previous month or otherwise
paid the tax due. It is unlawful for a wholesaler or distributor to stamp, sell, offer, or possess for sale cigarettes that are
manufactured by a manufacturer that is not in full compliance with this Act. A wholesaler or distributor can lose their
stamping privileges or registration number if they have activity with a manufacturer that is not in full compliance with the
above Act and the NPM Escrow Provisions of Title 6, Chapter 12. Pursuant to the above Act, the statement below must
be signed and notarized in order to complete the application process.
Under penalties of perjury, we hereby certify that we will comply fully with the provisions of the Tobacco Master
Settlement Complementary Legislation Act.
Firm: ___________________________________________________________________________________________
Signature: _______________________________________________________________________________________
Title: ___________________________________________________________________________________________
Sworn to and subscribed before me this the _________ day of_____________________, ___________.
Notary Public: ____________________________________________________________________________________
14. Do you plan to affix the Alabama revenue stamp to tobacco products?
Yes
No
15. Will tobacco product purchases be stamped with the Alabama revenue stamp by your suppliers?
Yes
No
OVER
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