Ets Form 140 - Cigarette Wholesaler'S Monthly Report - 1999 Page 3

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Wholesaler:_____________________________________________ License No:_____
For Month ending:____________
Retailer
Physical Address
City or County 20 Packs
25 Packs
Sales Tax License #
_____________________________ _______________________ _____________
__________________
_____________________________ _______________________ _____________
__________________
_____________________________ _______________________ _____________
__________________
_____________________________ _______________________ _____________
__________________
_____________________________ _______________________ _____________
__________________
_____________________________ _______________________ _____________
__________________
_____________________________ _______________________ _____________
__________________
_____________________________ _______________________ _____________
__________________
Total Packs
__________________
Please Note: Please add any new Retailer on the blank lines provided above. P O Boxes are
not acceptable, we need the physical location of the business for proper distribution.
Page 3

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