Form Cg-100-A - Application For License As A Cigarette Agent Or Agent / Wholesaler (Page 5 of 8) in pdf

Form Cg-100-A - Application For License As A Cigarette Agent Or Agent / Wholesaler Page 5

CG-100-A (1/02) Page 5 of 8

11. (a) Does any person, other than the applicant or a controlling

person listed in items 6 or 7:

Yes

11. (a)

(Provide full details of the interest, loan, or lien at 11(b))

have any interest (financial, proprietary or other, direct or

indirect) in the business to be licensed;

have any loans or advances outstanding to or from the

applicant;

have any lien or mortgage on the fixtures of the applicant’s

(b) Name and FEIN or SSN

business?

(b) If you answered Yes to 11(a), provide a complete description

of the interest, loan or lien, including name, address, and

Address

SSN, or FEIN of the person involved.

Nature of interest

Date acquired

12. (a) Will any person, other than the applicant or a controlling

person listed in items 6 and 7, share in any way the receipts,

Yes

12. (a)

(Provide full details of the sharing agreement at 12(b))

profits, losses, or deficiencies of the business (other than as

a salesperson receiving commissions at a level customary for

the industry)?

(b) If you answered Yes to 12(a), provide a complete description

(b) Name and FEIN or SSN

of the sharing agreement. See instructions for information

that must be included.

Address

Details - see instructions

13. (a) Does the applicant, or any controlling person listed in items 6

and 7, have any interest, direct or indirect, in any other

Yes

13. (a)

(Provide full details of the interest at 13(b))

business or premises where cigarettes or tobacco products

are manufactured, stocked or sold? For this question,

interest includes ownership or other beneficial interest;

debtor or creditor relationship; ownership of a security

(b) Name and FEIN of business

interest in any assets employed in such business; or role as a

director in such business. However, interests held in the form

of publicly traded securities need not be considered.

Address

(b) If you answered Yes to 13(a), provide a complete description

Type of business

of the interest, including the name of the applicant or

controlling person involved and the name, address and

federal identification number of the business.

Nature of interest

Date acquired

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Form Cg-100-A - Application For License As A Cigarette Agent Or Agent / Wholesaler Page 5

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