Form Boe-400-Ltr (S1f) - Renewal Application For Manufacturer/importer Tobacco Products License Page 2

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BOE-400-LTR (S1B) REV. 1 (7-12)
SECTION II: CANCELLATION NOTICE (complete this section only if you will not be maintaining your Tobacco
Products License)
I am no longer in business. Date business discontinued:
Daytime telephone number:
Mailing address:
SECTION III: OWNERSHIP CHANGE
A change in the ownership type of your business requires a new license to be issued. You can apply for accounts,
licenses, and permits using eRegistration (eReg) available on our website at eReg is also available
in our field offices. Please call our Taxpayer Information Section for assistance at 800-400-7115 (TTY:711).
I changed the ownership type of my business on:
FROM:
TO:
Daytime telephone number:
Mailing address:
SECTION IV: BUSINESS INFORMATION CHANGES (complete this section only if you have changes to any of the fields below)
EMAIL ADDRESS
BUSINESS TELEPHONE NUMBER
1. BUSINESS OR TRADE NAME (DBA if any)
(
)
2. BUSINESS ADDRESS (do not list PO Box or mailing service)
CITY
STATE
ZIP CODE
3. MAILING ADDRESS (if different from No. 2 above)
CITY
STATE
ZIP CODE
4. NAME OF BOOKKEEPER/ACCOUNTANT
ADDRESS
TELEPHONE NUMBER
(
)
Please use this address as my mailing address.
(check box and attach signed power of attorney form to use agent address for the account mailing address)
5. NAME OF REGISTERED AGENT FOR RECEIPT OF SERVICE OF PROCESS IN THIS STATE ADDRESS
TELEPHONE NUMBER
(
)
SECTION V: SIGNATURE (this section must be completed if you made any changes to Sections II, III, or IV)
SIGNATURE
EMAIL ADDRESS
DATE
PRINT NAME AND TITLE
TELEPHONE NUMBER
(
)

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