Form Ctp-134 - Cigarette And/or Tobacco Products Salesperson'S Permit Application printable pdf download

Form Ctp-134 - Cigarette And/or Tobacco Products Salesperson'S Permit Application

CTP-134: Cigarette and/or Tobacco Products

DEPARTMENT USE ONLY

Salesperson’s Permit Application

Permit Number

Period Covered

Date of Issuance

The undersigned hereby makes application for a permit to sell, solicit orders for, or engage in the sale for future delivery of cigarettes

and/or tobacco products for a specific employer. Read instructions on back before completing.

Last Name (please print)

First

M.I.

Phone Number

Date of Birth (mm/dd/ccyy)

(

)

–

Mailing Address

Social Security Number (required)

City

State

Zip Code

1. Current Business or Occupation (be specific)

2. Business or Occupation (if different than above during last three calendar years)

3. Have you as a sole proprietor, partner(s), limited liability company, member(s) or corporate officer(s) ever held, or now hold, a permit or certificate

issued by the Wisconsin Department of Revenue?

Yes

If Yes, indicate:

Type of permit or certificate

Permit or certificate number

Location for which permit or certificate was issued

4. Have you been found guilty of crimes relating to loaning money or anything of value to persons holding licenses or permit issued pursuant to ch.

125, Wis. Stats.?

Yes

5. Have you been convicted of violating federal or state laws or local ordinances other than traffic violations?

Yes

If Yes, check type of law violated:

Federal

State

Local Ordinances

Also indicate details of the violation, including nature of violation, date, place, court, and disposition.

6. If you have been convicted of a felony for which you received a pardon, describe the nature of the felony and date/place of the pardon.

7. Check the box(es) below which apply:

Application for permit to solicit sales for future delivery of cigarettes

Application for permit to solicit sales for future delivery of tobacco products (OTP)

(prefix(es) and number)

8. Name of the permittee which applicant will represent.

Permit Number

Address

City

State

Zip Code

I declare under penalties of the law that I have examined this information and to the best of my knowledge and belief, it is true,

correct and complete.

Signature (do not print or type)

Date

APPLICANT



SIGN HERE

CTP-134 (R. 1-12)

Form Ctp-134 - Cigarette And/or Tobacco Products Salesperson'S Permit Application

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