Cigarette Tax Stamps Order Form - Town Of Farmville

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TOWN OF FARMVILLE
116 North Main Street Post Office Drawer 368
Farmville, VA 23901
(434) 392-3333 FAX (434) 392-6135
CIGARETTE TAX STAMPS ORDER FORM
Applicant: __________________________________________________________________________
Mailing Address: ____________________________________________________________________
Federal Tax Identification Number: _____________________________________________________
The name of the store you are purchasing for: ___________________________________________
Signature: ____________________________________ Phone #: ____________________________
The above named applicant hereby applies to Carol A. Seal, Treasurer for the following number of
rolls/sheets of Cigarette Tax Stamps:
Type of Stamp Purchased:
Heat Applied
Self-Adhesive
(sold only in rolls of 15,000)
(sold only in sheets of 100)
Number of Stamps Purchased:
________________________
________________________
Dollar Value @ $.27 each
________________________
________________________
Less $.02 discount
________________________
________________________
Stamp Cost @ $.25 each
________________________
________________________
Mailing Fee $35.00/roll or $6.00/sheet ________________________
________________________
(IF MORE THAN 2 ROLLS – PLEASE CALL)
(N/A if billed to your FedEx account)
Total Due:
________________________
________________________
*****Make check payable to the Town of Farmville *****
Please indicate your FedEx account # if you want delivery by FedEx __________________________
If using your FedEx account, do you want insurance? _____ Amount to insure? $ ______________
══════════════════════════════════════════════════════════════════
OFFICE USE ONLY
═══════════════════════════════════════════════════════
Approved by Carol Anne Seal
______________________________________________
___________________
Signature
Date
Beginning Serial Numbers ____________________ Ending Serial Numbers ____________________
Date Payment Received _______________________ Amount Received ________________________
Date Picked Up ______________________ or Date Mailed ___________________________________
Signature ___________________________________________________________________________
(Authorized Representative of Company to Pick-up Stamps)
Revised 10/8/13

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