Form Ctl-1 - Cigarette Vending Machine Location List

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Rev. 3/03
Form CTL-1
Massachusetts
Cigarette Vending Machine
Department of
Location List
Revenue
Name of vending machine operator
Federal Identification or Social Security number
Street address
State
Zip
Number of locations (from Form CTL, line 17h)
This list must be filed with Form CTL, Application for All Cigarette Licenses, or at any time the Massachusetts Department of Revenue re-
quests an updated listing. Complete information must be provided below for each cigarette vending machine on location. Send this list with
Form CTL to: Massachusetts Department of Revenue, Cigarette Excise Unit, PO Box 7004, Boston MA 02204.
Location of vending machine
Name
Street address
City/Town
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