Dtf-719-Mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products Page 3
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1
2
3
4Part B - Vending machine registration certificates ($100 each)
Vendor name:
Vendor ID:
Period designator:
C16
In columns A through C, list the business name and physical address where each of your vending
machines is located and each machine's serial number. If you have several machines at one location,
enter the physical address only once, but enter the serial numbers of every machine at the location.
Attach additional copies of this page if necessary.
A
B
C
Business name
Physical address where vending machine is located
Serial number of each
(report each machine separately in column C)
vending machine
Total number of vending machine registration certificates required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Carry forward to next page or, if last page of Part B, enter this total on page 1, line 2, column A, as applicable.
72000306150094
DTF-719-C-MN (6/15)
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