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Form Cg-100-V - Application For License As A Wholesale Cigarette Dealer Who Only Operates Vending Machines Page 7

CG-100-V (1/02) Page 7 of 8

Business name

Address where vending machine is located

Manufacturer and

(report each machine separately)

machine serial number

Total number of machines in use

Total number of machines not in use

Grand total

17. For purposes of the application, the term controlling person means any person who is an officer, director, or partner (or in the case of

limited liability company, an officer, member or a person having with respect to such limited liability company authority analogous to that

of an officer or director with respect to a corporation) of an applicant for an agent’s or a wholesale dealer’s license under Article 20 of

the Tax Law, or if the applicant is a corporation, a shareholder, directly or indirectly, owning more than 10% of the number of shares of

voting stock of such corporation. It also includes persons who do or will exercise authority within the business comparable to the

authority normally exercised by corporate officers, regardless of the form of business organization or lack of actual title.

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 7