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

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

Warning

The Department of Taxation and Finance has the right to suspend or revoke a license to be an agent or wholesaler for violation

of the provisions of Article 20 of the Tax Law (Cigarette Tax) or Article 20-A of the Tax Law (Cigarette Marketing Standards Act.)

Making a false or misleading statement on this application may result in a denial or revocation of your license(s).

THIS CERTIFICATION MUST BE SIGNED AND DATED BY THE INDIVIDUAL APPLICANT AND

EACH MEMBER OF A PARTNERSHIP AND A MEMBER OF AN LLP OR LLC TREATED AS A

PARTNERSHIP BY THE IRS

The undersigned, each for himself/herself, certifies that he/she is the applicant named above; that he/she knows the contents of the above

application and the statements contained therein and the same are true, of his/her own knowledge.

Print name

Title

Signature

Date

THIS CERTIFICATION MUST BE SIGNED AND DATED FOR A CORPORATION OR AN LLP OR LLC

TREATED AS A CORPORATION BY THE IRS

certifies that he/she is

(Print name)

(Title)

of the above named applicant; that he/she knows the contents of the above application and the statements and answers therein; that the same are true of his/

her own knowledge; that he/she has been authorized, by said applicant, to make the statements and answers in this application on behalf of said applicant.

Date

(Signature of authorized officer)

Privacy Notification

The Commissioner of Taxation and Finance may collect and maintain personal information pursuant to the New York State Tax Law, including but not limited to,

sections 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that Law; and may require disclosure of social security numbers pursuant to

42 USC 405(c)(2)(C)(i).

This information will be used to determine and administer tax liabilities and, when authorized by law, for certain tax offset and exchange of tax information

programs as well as for any other lawful purpose.

Information concerning quarterly wages paid to employees is provided to certain state agencies for purposes of fraud prevention, support enforcement,

evaluation of the effectiveness of certain employment and training programs and other purposes authorized by law.

Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law.

This information is maintained by the Director of the Registration and Data Services Bureau, NYS Tax Department, Building 8, Room 338, W A Harriman

Campus, Albany NY 12227; telephone 1 800 225-5829. From areas outside the United States and Canada, call (518) 485-6800.

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 8

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