Form Cg-100-W - Application For License As A Wholesale Cigarette Dealer Other Than Those Who Only Operate Vending Machines Page 7
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8CG-100-W (1/02) Page 7 of 8
17. 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:
18. Does the applicant, or any person required to be listed in item 6 or 7, have a liability for any tax imposed by or pursuant to the authority
of the NYS Tax Law, or for the City of New York or for the City of Yonkers earnings tax on nonresidents, that has been finally determined
Yes
No
to be due and has not been paid in full?
(complete below)
Person’s name
Type of tax
Amount due
Assessment number
Assessment date
19. List all bank accounts of the applicant:
Bank name
Address
Account number
Type
20. 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.
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Parent category: Financial