Page 2 of 8 CG-100-W (1/02)
4. (a) Do you own or lease the premises listed in item 2 above? If
owned, you must provide a copy of the deed, and proceed to
Own
Lease
4. (a)
(attach copy of lease and Form CG-100-L)
item 5.
(b) If leased, state name and address of the immediate lessor, the
(b) Name and address of the immediate lessor
Date of lease
date of the lease and the date of expiration thereof. Enclose a
copy of the lease.
Date of expiration
(c) Do the terms of such lease require payment by the applicant
of any consideration based on a percentage of the receipts of
Yes
No
(c)
the business?
(d) If Yes , state percentage and give details.
(d) Percentage and details
(e) If location is not owned by applicant, does anyone required to
If Yes , please give name
be listed in items 6 or 7 have an ownership interest in the
Yes
No
(e)
premises?
5. (a) Will the applicant retail any cigarettes at the location listed in
item 2?
Yes
No
5. (a)
(b) If Yes , indicate the percentage to be sold at retail.
(b) Retail %
(c) Are there any retail sales of cigarettes at any other locations
operated by applicant?
Yes
No
(c)
(d) Does the applicant and/or controlling person as defined in
item 20 have any interest in any other business located in
Yes
No
(d)
the same building?
(e) If Yes , explain interest, relationship, type of products, and/or
(e) Details
services sold.
6. TO BE COMPLETED ONLY BY INDIVIDUAL OR PARTNERSHIP APPLICANTS, INCLUDING LLP’S AND LLC’S TREATED AS
PARTNERSHIPS BY THE IRS.
Name, Social Security Number (SSN) and
Home address
Citizenship
Duties
Home
date of birth (DOB) of sole applicant
(name of country)
(circle all that apply)
phone number
or partners of partnership
(
)
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
Attach additional sheets as needed. Please include the item number referenced on additional sheets.