Form Ctl - Application For All Cigarette Licenses - Except Retailer'S License - 2013-2014

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2013–2014

Form CTL

Massachusetts

Application for All Cigarette Licenses

Department of

Revenue

Except Retailer’s License

For DOR use only: License number

Decal number

Issued by

Date issued

Principal place of business.

Licenses will be mailed to this location.

Federal Identification or Social Security number (if sole proprietor)

E-mail address

Fax number

Type of identification number (check one):

Federal Identification number

Social Security number

Other:

Name of owner, partnership or other legal corporate name

Telephone number

Name of contact

Street address

City/Town

State

Zip

Name and address of location at which tobacco products will be sold

Trade name

Telephone number

Street address (do not use PO box)

City/Town

State

Zip

Types of business and respective fees

a. Quantity

b. Fee subtotal

Check all that apply, and complete columns A and B where applicable.

a Manufacturer ($250). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a

b Manufacturer branch ($125). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b

c Stamper (no fee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c

d Transportation company ($50) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d

e Unclassified acquirer ($250) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e

f Vending machine operator ($150). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f

g Vending machine operator branch ($75) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g

h Vending machine licenses ($50 each machine; complete and attach Form CTL-1).

Must be renewed every even-numbered year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h

i Wholesaler ($250). Must be filed with affidavits from three licensed manufacturers stating that

they will supply cigarettes to the applicant, if licensed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

j Wholesaler branch ($125) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . j

k Total. Add items a through j of col. b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . k

Make check or money order payable to Commonwealth of Massachusetts.

Type of organization.