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Dtf-719-Mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products Page 2

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.

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)

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)

Dtf-719-Mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products Page 2