Form Ap-175 - Texas Application For Non-Retailer Cigarette, Cigar And/or Tobacco Products Permit Page 3

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AP-175-3

(Rev.2-13/15)

Texas Application for Non-Retailer

Cigarette, Cigar and/or

• Type or print.

• Do NOT write in shaded areas.

Tobacco Products Permit

Page 2

12. Legal name of owner (same as Item 1)

For Comptroller Use Only

13. Business location name

Job name

•

MISCAPP

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

00991

Address must be a commercial location. Public storage units, rural routes or P.O. Boxes are not allowed.

•

City

State

ZIP code

Reference No.

•

County

14. Enter the daytime phone

Area code

Number

•

number of the person primarily

responsible for the business

15. Is this location inside the city limits? ...........................................................................................................

YES

16. Is this location a customs bonded warehouse? ..........................................................................................

YES

If "YES," please explain.

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

month

day

year

18. What is the first business date that this business location will

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

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

YES

If "YES," please provide your email or Web page address:

NOTE: State law requires all Internet and mail order cigarette sellers planning to deliver cigarettes to a purchaser in Texas

to register their business with the state and collect all applicable state taxes and remit them to the Comptroller's office.

20. Indicate the permit type needed for cigarettes:

Manufacturer

Wholesaler

Distributor

Bonded agent

Importer

21. Indicate the permit type needed for other tobacco products:

Manufacturer

Wholesaler

Distributor

Bonded agent

Importer

22. Provide your current Dept. of Treasury, Alcohol & Tobacco Tax & Trade Bureau (T.T.B.) permit number(s) for cigarette and/or tobacco products:

23. 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):

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

Manufacturer will stamp all complimentary cigarettes.

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

Manufacturer will pay the tax directly to the State of Texas

Not applicable: Federal military/Native American Reservation sales

for complimentary tobacco products.

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

YES

If "YES," please list the other states:

26. Will you sell cigarettes, cigars and/or tobacco products from a motor vehicle? ........................................

YES

If "YES," please complete the following (Use additional sheets or complete Form 69-122, if necessary.):

YEAR

MAKE

MODEL

LICENSE PLATE NO.

STATE

MOTOR VEHICLE ID NUMBER IN-SERVICE DATE

27. If your place of business is a vehicle, where will business records for the vehicle(s) listed above be maintained? (Use street address or directions,

city, state and ZIP code - NOT P.O. Box, rural route or public storage.) — Must be a commercial location.

28. Will you sell or store cigarettes, cigars and/or tobacco products at the location

where the records will be kept? ..................................................................................................................

YES