Form Cg-100-W - Application For License As A Wholesale Cigarette Dealer Other Than Those Who Only Operate Vending Machines Page 4
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8Page 4 of 8 CG-100-W (1/02)
(f) The names, SSN’s, and home addresses of all directors 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
Citizenship
Duties
Home
director(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
8. (a) Has the applicant or any controlling person as defined in
item 20 ever been convicted (including pleas of guilty or no
Yes
No
8. (a)
contest) of any felony or of any other crime or offense of any
kind except violations of the Vehicle and Traffic Law?
(b) Date, crime or offense, and name of person convicted
(b) If Yes , state date of conviction, crime or offense involved, and
name of person convicted. In each case a Certificate of
Disposition or a Certificate of Conviction from the court clerk
must be attached.
9. (a) Are there any arrests, indictments, or summonses (except for
violations of the Vehicle and Traffic Law) pending against the
Yes
No
9.
(a)
applicant or any controlling person as defined in item 20?
(b) If Yes , state date thereof, crime or offense charged, name of
(b) Date, crime or offense, name of defendant and
each defendant and jurisdiction.
jurisdiction
10. (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
No
10. (a)
country, ever made by the applicant, applicant’s spouse, or
controlling person as defined in item 20?
(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
(c) Has such license or permit ever been denied, revoked,
cancelled, suspended, or otherwise involuntarily terminated
Yes
No
(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.
Attach additional sheets as needed. Please include the item number referenced on additional sheets.
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