Part A - Certificates of registration for retail operations ($300 each)
The Seq. no. box is for office use only. In column A, enter your business name [trade name, DBA (doing business as) name,
or assumed name if different from your legal name] and physical address for each business location. In column B, indicate
whether you are currently making retail sales of cigarettes and/or tobacco products for each location listed. In column C,
mark an X if the business is no longer selling cigarettes, but is open for other types of sales. In column D, enter the date you
stopped all business activity at the location listed. In column E, enter the date you plan on beginning business if you are
adding a new location for 2016 (attach Form DTF-17-ATT). Attach additional copies of this page if necessary.
A
B
C
D
E
Seq.
Business name and physical address
Y = yes
Location no longer selling
Location closed for all
Adding new location;
no.
enter beginning
N = no
cigarettes, but open for
business; enter
business date (Form
other types of sales
out-of-business date
DTF-17-ATT required)
(mm/dd/yy)
(mm/dd/yy)
Totals from additional copies of page (if attached) . . . . . . . . . .
Total number of certificates of registration required . . . . . .
Enter this total on page 1, line 1, column A, as applicable.
72000206150094
DTF-719-MN (6/15) (back)