Form Cg-100-W - Application For License As A Wholesale Cigarette Dealer Other Than Those Who Only Operate Vending Machines Page 3
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8CG-100-W (1/02) Page 3 of 8
7. TO BE COMPLETED ONLY BY CORPORATE APPLICANTS, INCLUDING LLP’S AND LLC’S TREATED AS CORPORATIONS BY THE
IRS.
(a) State (country) of incorporation:
Date of organization:
(If applicant is not a New York State corporation, please refer to instructions for additional requirements.)
(b) Address of corporate headquarters:
Street:
City, State, ZIP:
Country:
(c) List the owner(s) of the applicant. List all shareholders who own or control, directly or indirectly, more than 10% of its voting stock. If
any person is not a natural person, refer to instructions.
Percent of stock
When
Name, SSN and date of birth (DOB) of
Home address
Citizenship
Duties
Home
acquired
shareholder(s)
(name of country)
common preferred
phone number
(circle all that apply)
common
(
)
Area code
A B C D E F G
Name
Other
preferred
SSN
DOB
common
(
)
Area code
A B C D E F G
Name
Other
preferred
SSN
DOB
common
(
)
A B C D E F G
Area code
Name
Other
preferred
SSN
DOB
(d) Enter the total percent of voting shares held by persons not listed in item 7(c).
Common
%
Preferred
%
Enter the percentage of ownership held directly or indirectly by the largest
shareholder in the group.
Common
%
Preferred
%
Enter the total number of shareholders, excluding those listed in item 7(c).
Common
Preferred
(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
Attach additional sheets as needed. Please include the item number referenced on additional sheets.
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Parent category: Financial