Form Cm-100 - Combined Cigarette License Application
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1Division Use Only — DLN Stamp
Division Use Only — Date Stamp
Division of Revenue
Send to:
1-2011
PO Box 252
ENCLOSE FEE WITH APPLICATION
Trenton, NJ 08646-0252
Retail Over-the-Counter
Combined Cigarette
Form CM-100
Vending Machine
License Application
Manufacturer Representative
Check One Box for the License Desired
Enclose Fee
Cigarette Retail Dealer’s Over-the-Counter License — 1 year license
$ 50
00
Complete Sections A & B below
Cigarette Vending Machine License — 1 year license each machine
$ 50
each
00
Complete Sections A & C below
Cigarette Manufacturer Representative License — 1 year license
$ 5
00
Complete Sections A & D below
Initial Application
Section A —
Licensee Information
Check one:
Renewal Application
Taxpayer Name
Start Date for Business in New Jersey
Trade Name
FEIN (for businesses)
Social Security N
(for individuals)
o
Business Address
Mailing Address
Check Type of Ownership
For all corporations, give State of Incorporation:
Corporation
LLC
Partnership
LLP
Proprietorship
Representative
Other (specify)
Point of Contact:
Phone N
Email
o
OWNERS’ INFORMATION (attach list if needed)
Name
Title
Social Security N
Home Address
o
Provide information about those from whom you
Section B —
Retail Over-the-Counter License
purchase cigarettes – attach list if needed
Supplier
Supplier’s FEIN
Supplier’s Address
City
State
Phone N
o
$ 50
00
Provide information about the machines you will
Section C —
Vending Machine License
operate — attach list if needed
Supplier
Supplier FEIN
Phone N
o
Address where machine is located
City
State
$ 50
00
each
Section D —
Manufacturer Representative License
Provide information on the company you represent
Company
FEIN
Address
City
State
Phone N
o
$ 5
00
By signing, signatory affirms that all information is complete and
accurate.
Should
any
information
be
incomplete
or
inaccurate, the application will not be processed.
The Application Fee must be enclosed to process the
application
Authorized Signature
$
Total Fee Enclosed:
Printed Name
Title
Date
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Parent category: Financial