Form Cig - 1a - Application For Cigarette Distributor'S Registration Certificate
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1
2INDIANA DEPARTMENT OF REVENUE
FOR OFFICE USE ONLY
P.O. BOX 901
CIG
ATTN: SPECIAL TAX LICENSING
INDIANAPOLIS, IN 46206-0901
*This form must be submitted 30 days prior to:
CIG - 1A
a) the expiration of your current license or,
SF 48477
b) the date you begin your business.
(R2 /10-07)
You may not do business without your certifi cate.
APPLICATION FOR CIGARETTE DISTRIBUTOR’S REGISTRATION CERTIFICATE
Renewal
New Certifi cate
Applicant’s Name - Enter individual, partnership, or corporation name
Federal ID Number
Business/Trade Name (if different than above)
Telephone Number
Owner’s Social Security #
Mailing Address (Street or P.O. Box Number)
City or Town
County
State
Zip Code
Physical Address of Business
City or Town
County
State
Zip Code
Type of Ownership:
Sole Proprietorship
Partnership
Corporation
If Corporation: Date of Incorporation:
If Foreign Corporation: Date of Acceptance by Indiana Secretary of State:
If an Indiana Corporation or a Foreign Corporation, Give Name and Address of Resident Agent:
Identifi cation of Partners or Corporate Offi cers:
Name (last name fi rst)
Social Security Number
Address
City
State
Zip Code
Title
Are You registering to be a STAMPING DISTRIBUTOR?
Yes
No
Does Applicant Presently Hold an OTP License?
Yes
Number
No
Does Applicant Presently Hold a Cigarette License?
Yes
Number
No
Has Applicant Previously Held a Cigarette License?
Yes
Number
No
Does Applicant Presently Hold an Indiana
Registered Retail Merchants Certificate?
Yes
Number
No
Does Applicant Presently Hold Any Other License or
Permits Issued by any State Agency? (Please List Below)
Yes
No
STATE AGENCY
TYPE OF LICENSE OR PERMIT
NUMBER
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Parent category: Financial