Form Reg-L - Request For Cigarette And/or Motor Fuel License Applications - State Of New Jersey Division Of Taxation

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REG-L
State of New Jersey
Mail to:
CN 252
DIVISION OF TAXATION
(12-96)
Trenton, NJ
08646-0252
Request for Cigarette
and/or Motor Fuel License Applications
Federal Identification Number / Social Security Number
Name
Trade Name
Address
City
State
Zip Code
IF YOU ARE REQUESTING A LICENSE APPLICATION
CHECK THE APPROPRIATE BOX(ES) BELOW AND
RETURN IT WITH YOUR COMPLETED REG-1.
CIGARETTE TAX LICENSE TYPES
(see reverse side for definitions)
Wholesaler
Distributor
Manufacturer
MOTOR FUEL TAX LICENSE TYPES
(see reverse side for definitions)
Wholesaler
Seller / User
Distributor
Gasoline Jobber
Import
Storage Facility Operator
Export
______________________________________________________________________________________________________________
Signature
Date
_____________________________________________________________________
(_________) ____________________________
Title
Telephone
- 15 -

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