CT101
2014-15
License Application for Tobacco Products Distributors and Subjobbers
Check license applied for:
New application
Renewal
Business legal name
Daytime phone
Minnesota tax ID number
Doing business as
Federal ID number
Physical Street
County
Email address
Physical City
State
Zip code
Fax number
Mailing Street
County
Mailing City
State
Zip code
Fax number
Type of Business
Individual
Partnership or association
Corporation
State of incorporation
Date of incorporation
Corporate officers, partners or members of association (attach a list if necessary)
Name
Title
Social Security number
Address
City
State
Zip code
Name
Title
Social Security number
Address
City
State
Zip code
Name
Title
Social Security number
Address
City
State
Zip code
Name
Title
Social Security number
Address
City
State
Zip code
Your application cannot be processed without answers to the following questions.
All applicants
1 Do you acquire tobacco products for the purpose of sale to retailers or other persons for resale? . . . . . . . .
Yes
No
2 Are any of these products acquired before Minnesota tax is paid on them? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
3 Have you ever been convicted of a cigarette or tobacco crime? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
4 Have you ever had a license revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
5 Will you be making sales on a Minnesota reservation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Tobacco subjobbers only
6 Do you acquire tax paid tobacco products for the primary purpose of resale to retailers? . . . . . . . . . . . . . . .
Yes
No
All applicants: You must complete the reverse side . Incomplete applications will be returned to you .
1
(Rev . 10/13)