Form Cig - 1a - Application For Cigarette Distributor'S Registration Certificate Page 2
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1
2Audit Information:
Location Where Records Will Be Available For Audit:
Phone Number of Location Of Audit Records:
Phone Number of Business Location:
Indicate Address and Certifi cate Number of Each Location In Which You Have Cigarettes in Storage
Location
Cigarette Number
From What Source do you intend to buy Cigarettes?
_____ A. Direct from Manufacturer
_____ B. Wholesaler outside the State of Indiana: Unstamped ________
Stamped________
_____ C. Indiana Distributor:
Unstamped ________ Stamped ________
IF YOU INTEND TO PURCHASE CIGARETTES PRESTAMPED FOR RESALE IN INDIANA, YOU MUST
PROVIDE THE FOLLOWING INFORMATION FOR AT LEAST TEN CUSTOMERS.
RETAIL MERCHANTS
RETAILER
ADDRESS
PHONE NUMBER
CERTIFICATE NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Does Your Company Expect to Sell Cigarettes Into Another State? Yes _____
No_____
If Yes, List the State(s) and License/Certifi cate Number(s):__________________________________________
I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and state-
ments, is true, correct and complete to the best of my knowledge and belief.
Signature of Taxpayer or Agent
Title
Telephone Number
Date
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Parent category: Financial