Form Cg-100-A - Application For License As A Cigarette Agent Or Agent / Wholesaler

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New York State Department of Taxation and Finance
CG-100-A
Application for License as a Cigarette Agent
(1/02)
or Agent / Wholesaler
For office use only
Article 20 of the Tax Law
Send completed application and all required documentation to:
NEW YORK STATE TAX DEPARTMENT
TTTB - REGISTRATION AND BOND UNIT
WA HARRIMAN CAMPUS — 855
ALBANY NY 12227
Read the instructions carefully before completing this application. Attach additional sheets as necessary
to fully answer all questions. Unanswered questions will delay the processing of this application.
Reason for application
:
Currently licensed and adding location(s)
Transfer of license
(refer to instructions)
New applicant
Relicensing
Type of application:
Agent only
Agent / wholesaler
1. Print or type
(a) Legal name
(b) Trade name
(if different from item a)
(c)
Cigarette related activities you are currently or will be involved in
(check all applicable boxes)
Manufacturer
Importer
Retailer
Wholesaler
Exporter
Applying NYS Cigarette Tax Stamps
Other
2. Street address of all stamping / storage locations
Mailing address
City, town or village, state, ZIP code
Telephone number
City, town or village, state, ZIP code
(
)
Between what streets or avenues. (If outside city limits and not known by a house number, specify location in relation to nearest intersecting road or highway.)
State the specific location in the building where your business is to be conducted.
3. (a) Type of organization
(b) Federal employer identification number (FEIN) (c) Other FEIN(s), if any
(check only one box)
Individual
Corporation
(d) Date business began or will begin in New York State
Partnership
LLP
LLC
Other
(specify)
Attach additional sheets as needed. Please include the item number referenced on additional sheets.

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