Form 04-520 - Cigarette And Tobacco Products Tax License Application

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Alaska Department of Revenue
Voice: (907) 465-4683
Cigarette and Tobacco Products Tax
Income and Excise Audit Division
Fax: (907) 465-2375
PO Box 110420
E-Mail: edie_bundy@
License Application
Juneau, AK 99811-0420
revenue.state.ak.us
For the Period July 1, 1998 – June 30, 1999
AS 43.50.010 – 390
NOTE: Except for vending machine operators, all persons operating more than one place of business must obtain a separate license
for each place of business.
Licensee Information
Federal EIN or SSN
Taxpayer Name
Business Name
Mailing Address
City, State Zip Code
Telephone Number
Fax Number
E-mail Address
Contact Name
Physical Location
Type of License (Check correct box)
See other side for definitions of license types. The license fee must accompany the application
Make your check payable to: Alaska Department of Revenue.
Cigarettes and Tobacco Products
q Buyer ....................................................................................................................................................................$25.00
q Direct-Buying Retailer ...........................................................................................................................................$25.00
q Distributor .............................................................................................................................................................$50.00
q Manufacturer.........................................................................................................................................................$ 5.00
q Vending Machine Operator ...................................................................................................................................$25.00
q Wholesaler-Distributor ..........................................................................................................................................$50.00
Tobacco Products Only (Persons who exclusively import and/or acquire tobacco products)
q Distributor .............................................................................................................................................................$50.00
Explain, in general, the nature of your business. Indicate the sources of your purchases, and to whom you distribute.
I certify that an accurate record will be kept of cigarettes and other tobacco products manufactured, imported, acquired or sold
from any source whatever and that the required returns will be filed on or before the last day of each calendar month and that the
tax due will be paid.
Signature
Title
Date
Form 04-520 (Revised 2/98)

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