License Application to Make Retail Sales of Cigarette and Other Tobacco Products
To be completed by applicant when applying for a license with a city or county.
FOR MUNICIPAL USE ONLY
Applicant’s Minnesota tax ID number
The Minnesota tax ID must be issued in the same
legal name of the licensee below.
Cigarettes/tobacco products will be sold (a separate license is required
for each location or vending machine):
Date of issuance
Through vending machine
Licensee’s legal name
Federal employer ID number (FEIN)
Business trade name (doing business as)
Complete address of business location (permit location)
Other phone number
Mailing address (if different than business address)
Type of legal organization (check one):
Minnesota corporation: Enter date of incorporation
Out-of-state corporation: State of incorporation
Are you registered to do business in Minnesota?
Corporate officers or partners (attach a list if necessary)
As a licensed tobacco products or cigarette retailer, I understand that:
1. I can purchase cigarettes only from a Minnesota distributor or subjobber who holds a license with the Minnesota Department of
2. I must obtain a tobacco products distributor license if I purchase untaxed tobacco products from an out-of-state company.
3. I may not sell cigarettes affixed with Minnesota Native American stamps unless my retail business is located on a reservation that
has a tax agreement with the State of Minnesota.
4. I may not purchase from or exchange cigarettes or tobacco products with another retailer.
5. I must keep complete and legible cigarette and tobacco products invoices on the licensed premises, or make invoices available
within one hour of request, for at least one year after the date of the purchase.
6. I know that the Minnesota Department of Revenue and/or law enforcement may conduct cigarette and tobacco inspections of
the premises, including inspections of inventory, invoices and licenses, and I understand that a refusal to allow an inspection is
grounds for revocation of my license.
7. I know that failure to comply with all requirements can result in criminal penalties, including the loss of cigarettes and tobacco
Licensing agent’s signature
License applicant: Submit this form to the licensing authority along with the license application.
Licensing authority: Mail or fax a copy of approved form to:
Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331.