Form Cg-100-V - Application For License As A Wholesale Cigarette Dealer Who Only Operates Vending Machines Page 5
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8CG-100-V (1/02) Page 5 of 8
10. (a) Has the applicant or any controlling person as defined in
item 17 ever been known by any other name or names
Yes
No
10. (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:
11. (a) Does anyone, other than the applicant, licensed under
Article 20 or 20A of the Tax Law occupy any portion of the
Yes
No
11. (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
12. 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
Agent
If No , include Form DTF-17, Application for Registration
as a Sales Tax Vendor
Wholesaler
Cigarette retailer
(e) Other taxes
Yes
No
If Yes , enter identification number and type of tax
(b) Corporation tax
Yes
No
ID number
Type of tax
If Yes , enter identification number
(c) Withholding tax
Yes
No
If Yes , enter identification number
13. List applicant’s license or certificate numbers issued by the City of New York for the following, if applicable:
Not applicable
City of New York
License or certificate number
Date issued
Cigarette agent
Wholesale cigarette dealer
Retail cigarette dealer
Yes
No
Has a City of New York cigarette license or agent’s Certificate of Authority ever been surrendered, cancelled, or expired?
If Yes , explain:
Attach additional sheets as needed. Please include the item number referenced on additional sheets.
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Parent category: Financial