Form Cg-100-V - Application For License As A Wholesale Cigarette Dealer Who Only Operates Vending Machines Page 3
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8CG-100-V (1/02) Page 3 of 8
(e) The names, SSNs, and home addresses of all officers of the corporation as of the date of filing of this application are as follows:
Name, SSN and date of birth (DOB) of
Home address
Title of officer
Citizenship
Duties
Home
officer(s)
(name of country)
(circle all that apply)
phone number
A B C D E F G
(
)
Area code
Name
Other
SSN
DOB
(
)
A B C D E F G
Area code
Name
Other
SSN
DOB
A B C D E F G
(
)
Area code
Name
Other
SSN
DOB
(f) The names, SSN’s, and home addresses of all directors of the corporation as of the date of filing of this application are as follows:
Name, SSN and date of birth (DOB) of
Home address
Citizenship
Duties
Home
director(s)
(name of country)
(circle all that apply)
phone number
A B C D E F G
(
)
Area code
Name
Other
SSN
DOB
(
)
A B C D E F G
Area code
Name
Other
SSN
DOB
(
)
A B C D E F G
Area code
Name
Other
SSN
DOB
6. (a) Has the applicant or any controlling person as defined in
item 17 ever been convicted (including pleas of guilty or no
Yes
No
6. (a)
contest) of any felony or of any other crime or offense of any
kind except violations of the Vehicle and Traffic Law?
(b) Date, crime or offense, and name of person convicted
(b) If Yes , state date of conviction, crime or offense involved, and
name of person convicted. In each case a Certificate of
Disposition or a Certificate of Conviction from the court clerk
must be attached.
7. (a) Are there any arrests, indictments, or summonses (except for
violations of the Vehicle and Traffic Law) pending against the
Yes
No
7.
(a)
applicant or any controlling person as defined in item 17?
(b) If Yes , state date thereof, crime or offense charged, name of
(b) Date, crime or offense, name of defendant and
each defendant and jurisdiction.
jurisdiction
Attach additional sheets as needed. Please include the item number referenced on additional sheets.
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