Form Cg-80 - Application For Registration As A Chain Store

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For office use only
CG-80
New York State Department of Taxation and Finance
Application for Registration
(11/04)
as a Chain Store
Pursuant to Tax Law Article 20-A, Cigarette Marketing Standards Act
A chain store registration is granted exclusively to the applicant and is not transferable.
Read Form CG-80-I, Instructions for Form CG-80, carefully before completing this application. Attach additional sheets as necessary to fully
answer all questions. Once registration is granted, the certificate of chain store registration must be publicly displayed at your place of
business (other than individual vending machines). Keep a copy for your records.
Mark an X in the appropriate box for this application.
(For definitions and information required to be submitted with this form, see Definitions and
Documentation requirements on Form CG-80- I .)
Registration fee
Cooperative member ....................................................................................................................................................
$300*
Name of cooperative
FEIN of cooperative
Franchisee ....................................................................................................................................................................
$300*
Name of franchisor
FEIN of franchisor
Vending machine operator (must have 15 or more marketing locations within NYS) ...................................................
$250*
NYS wholesale dealer license number
CWV –
Large volume outlet operator (one fee based per operator, not per outlet) .................................................................
$300*
Business with 15 or more retail outlets ......................................................................................................................
$300*
Currently licensed (reporting additional registered locations or vending machines) .....................................................
No fee
*If the registration fee has been paid within the preceding 12 months, the registration fee is $200.
Print or type
1. Legal name
2. Trade name/dba
(if different from above)
3. Address of principal place of business
(number and street; see instructions)
City
State
ZIP code
4. County
(principal place of business)
5. Telephone number of principal place of business
6. Date business began or
7. FEIN
8. Other FEIN, if any
will begin in New York State
(
)
/
/
9. Type of organization
(mark an X in one or more boxes)
Sole proprietor
Partnership
Corporation
:
Other
(specify)
10. Mailing address
City
State
ZIP code
(if different from business address)

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