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Form Cg-100-V - Application For License As A Wholesale Cigarette Dealer Who Only Operates Vending Machines Page 4

Page 4 of 8 CG-100-V (1/02)

8. (a) Was any application for a license or permit under the

cigarette laws of this state or country, or of any other state or

Yes

8. (a)

country, ever made by the applicant, applicant’s spouse, or

controlling person as defined in item 17?

(b) Name of applicant

(b) If Yes , state name of such applicant, address of premises,

date of filing of application, and disposition thereof. Give

license number if license or permit was issued.

Address of premises (street, city, town or village, state, or country)

Date filed, disposition, and license number, if any

cancelled, suspended, or otherwise involuntarily terminated

Yes

(c)

or surrendered in lieu of cancellation, or has any other

penalty been imposed in connection therewith at any time?

(d) Action and date

(d) If Yes , state what action was taken, and date thereof.

9. (a) Does the applicant, or any controlling person listed in items 4

and 5, have any interest, direct or indirect, in any other

Yes

9. (a)

(Provide full details of the interest at 9(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 9(a), provide a complete description of

Type of business

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-V - Application For License As A Wholesale Cigarette Dealer Who Only Operates Vending Machines Page 4