Form M-100a - Application To Purchase Cigarette Tax Stamps

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FORM M-100A
STATE OF HAWAII — DEPARTMENT OF TAXATION
(REV. 2008)
APPLICATION TO PURCHASE CIGARETTE TAX STAMPS
£
£
Initial Application
Amended Application (This supercedes all previous applications.)
Information About the Licensee
Name
Cigarette Tax and Tobacco Tax License Number ______
DBA
Check one:
£
Wholesaler
£
Type of organization (e.g. Corporation, Partnership, Individual, etc.)
Dealer
Hawaii Tax Identification
Number: W __ __ __ __ __ __ __ __ - __ __
Address
SSN/FEIN:
Telephone number:
______________________
City
State
Zip Code
List the owners, partners, members, or principal corporate officers (Attach additional sheet if needed) Please print.
SSN
Title
Address
Phone No.
Name
I declare, under the penalties set forth in section 231-36, HRS, that the information contained in this application has been
examined by me and, to the best of my knowledge and belief, is true and correct.
Signature of Owner, Partner, Member, or Principal Corporate Officer
Date
Print Name of Signatory
Title
DEPARTMENT OF TAXATION USE ONLY
Upon approval, the above named licensee is authorized to purchase Hawaii Cigarette Tax Stamps.
APPROVED BY ________________________ Approval Number CIG-
FORM M-100A

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