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Form Dtf-716 - Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes Or Tobacco Products - 1999 Page 2

Page 2 DTF-716 (8/99)

Part A - Certificates of registration for retail operations ($100 each)

In columns A and B, list the business name and address for each of your business locations registered for sales tax through which you are or will

be making retail sales of cigarettes or tobacco products. In column C, indicate the date you began or will begin selling these products at each

location. Attach additional sheets if needed.

Business name

Business address

Date

Total number of certificates of registration required

......................

(enter this total on page 1, line 4, column C)

Part B - Vending machine registration stickers ($25 each)

In columns A through C, enter the business name and address where each of your vending machines is located and its serial number. If

you have several machines at one location, enter the address only once, but list the serial number of every machine at the location. Attach

additional sheets if needed.

Address where vending machine is

Machine serial

Business name

located (report each machine separately)

number

Total number of vending machine registration stickers required

(enter this total on page 1, line 5, column C)

Note:

Vending machine registration stickers and certificates of registration for the period January 1, 2000, through

December 31, 2000, will not be issued before December 1, 1999.

Form Dtf-716 - Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes Or Tobacco Products - 1999 Page 2