Form Cg-100-A - Application For License As A Cigarette Agent Or Agent / Wholesaler Page 6

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Page 6 of 8 CG-100-A (1/02)
14. (a) Has the applicant or any controlling person as defined in
item 20 ever been known by any other name or names
Yes
No
14. (a)
(including maiden name)?
(b) If Yes , state current and former name or names, aliases,
(b) Current name and SSN
dba’s, etc., social security numbers, and the reason for
change.
Former name(s) and SSN
Reason(s) for change:
Current name and SSN
Former name(s) and SSN
Reason(s) for change:
15. (a) Does anyone, other than the applicant, licensed under
Article 20 or 20A of the Tax Law occupy any portion of the
Yes
No
15. (a)
premises listed in item 2?
(b) If Yes , state full name of licensee and license number.
(b) Name of licensee
If purchasing a business, you must submit a copy of the
contract of sale.
License number
16. Does the applicant have current registrations or tax accounts with New York State for the following taxes?
(a) Cigarette tax
Yes
No
(d) Sales tax
Yes
No
If Yes , enter identification number
If Yes , enter identification number
If No, include Form DTF-17, Application for Registration
Agent
Wholesaler
as a Sales Tax Vendor
Cigarette retailer
(b) Corporation tax
Yes
No
(e) Other taxes
Yes
No
If Yes , enter identification number
If Yes , enter identification number and type of tax
ID number
Type of tax
(c) Withholding tax
Yes
No
If Yes , enter identification number
Attach additional sheets as needed. Please include the item number referenced on additional sheets.

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