Form 69-121 - Business Location Supplement For Cigarette And/or Tobacco Products Permit

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69-121

PRINT FORM

CLEAR FIELDS

(Rev.7-09/4)

BUSINESS LOCATION SUPPLEMENT FOR

CIGARETTE AND/OR TOBACCO PRODUCTS PERMIT

• Please type or print.

NOTE:

Use this supplement to add additional commercial business locations for your existing

• Please attach copies if necessary.

Cigarette and/or Tobacco Products Permit.

1. Legal name of owner

2. Taxpayer number

3. Business location name

•

4. Business location address where cigarettes or cigars/tobacco products are sold, kept for sale or consumption, or are otherwise stored

•

City

State

ZIP Code

•

County

5. Enter the daytime phone

•

(

)

number of the person primarily

responsible for this business.

6. Is this a commercial business location? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

YES

7. Is this location inside the city limits? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

YES

8. Does this location include a humidor? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

YES

9. Is this location a customs bonded warehouse? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

YES

If "YES," please explain.

10. Describe the nature of your business at this location. (Use additional sheets if necessary.)

Month

Day

Year

11. What is the first business date that this business location

will conduct sales of cigarettes, cigars, and/or tobacco products? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

12. Are you planning to sell cigarettes over the Internet/mail order? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

YES

If "YES", please provide your e-mail or Web page address:

NOTE: State law requires all Internet and mail order cigarette sellers to register their business with the state and collect all applicable state taxes and

remit them to the Comptroller's office.

13. Indicate the permit types needed:

Retailer

Wholesaler

Distributor

Bonded Agent

Manufacturer

Importer

14. Indicate the product type:

Cigarette only

Tobacco only

Cigarette and Tobacco

15. Provide your current Dept. of Treasury, Alcohol & Tobacco Tax & Trade Bureau (T.T.B.) permit number(s)

for cigarette and/or tobacco products

16. Will you store unstamped cigarettes and/or tax-unpaid tobacco products for which tax is due? _ _ _ _ _ _ _ _ _ _ _ _

YES

If "YES," for whom will you store unstamped cigarettes and/or tax-unpaid tobacco products? (Use additional sheets, if necessary)

17. Indicate how your company will handle sample complimentary products:

Manufacturer will stamp all complimentary cigarettes

Manufacturer will ship to a licensed distributor to stamp or pay the tax

Manufacturer will pay the tax directly to the State of Texas for complimentary tobacco products

Not applicable (Federal military/native American reservation sales)

18. Will you stamp cigarettes in Texas with another state's stamp? ........................................................................................

YES

If "YES," please list other states:

For Comptroller Use Only

If you purchased an existing business or business assets, complete Items 19-22; otherwise, skip to Item 23.

Job name

19. Enter the former owner's trade name. If known, enter the former owner's Texas taxpayer number.

MISCAPP

•

Trade name

Taxpayer number of former owner

00991

•