Form Ctp-129 - Application For Cigarette And Tobacco Products Permits/registration Page 4
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8AUXILIARY QUESTIONNAIRE
To be completed by each individual, partner, or member and each officer, director, agent, and holder of 5% or
more stock of a corporation.
1. Name of Individual, Partner, Member, Officer, etc.
2. Social Security Number
3. Date of Birth
4. Home Address and Phone Number
5. Legal Name
6. City
State
Zip Code
7. Position With Applicant
8. Percent of Stock Held
Yes
No
9. Are you a resident of Wisconsin?
If No, and you are a sole proprietor, partner, member, or foreign or domestic corporation, you must com-
plete the “Appointment of Department of Financial Institution’s (DFI) Service of Process” by Nonresident
or Foreign Corporation.
Yes
No
10. Have you been found guilty of crimes relating to loaning money or anything of value to persons holding
licenses or permits issued pursuant to ch. 125, Wis. Stats.?
Yes
No
11. Have you been convicted of violating federal or state laws or local ordinances other than traffic violations?
If Yes, check type violated:
Federal
State
Local ordinances
Also provide details of violation (nature of violation, date, place, court, and disposition)
12. If you have been convicted of a felony, describe the nature of the felony. If pardoned, give date, and place of pardon and attach a
copy to the application.
I declare under penalties of the law that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
Date
Your Signature
Wisconsin Department of Revenue
AUXILIARY QUESTIONNAIRE
To be completed by each individual, partner, or member and each officer, director, agent, and holder of 5% or
more stock of a corporation.
1. Name of Individual, Partner, Member, Officer, etc.
2. Social Security Number
3. Date of Birth
4. Home Address and Phone Number
5. Legal Name
6. City
State
Zip Code
7. Position With Applicant
8. Percent of Stock Held
Yes
No
9. Are you a resident of Wisconsin?
If No, and you are a sole proprietor, partner, member, or foreign or domestic corporation, you must com-
plete the “Appointment of Department of Financial Institution’s (DFI) Service of Process” by Nonresident
or Foreign Corporation.
Yes
No
10. Have you been found guilty of crimes relating to loaning money or anything of value to persons holding
licenses or permits issued pursuant to ch. 125, Wis. Stats.?
Yes
No
11. Have you been convicted of violating federal or state laws or local ordinances other than traffic violations?
If Yes, check type violated:
Federal
State
Local ordinances
Also provide details of violation (nature of violation, date, place, court, and disposition)
12. If you have been convicted of a felony, describe the nature of the felony. If pardoned, give date, and place of pardon and attach a
copy to the application.
I declare under penalties of the law that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
Date
Your Signature
Wisconsin Department of Revenue
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