Form 73a181- Application For Cigarette And Tobacco Products Licenses
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373A181 (6-13)
FOR DEPARTMENT USE ONLY
APPLICATION FOR
Commonwealth of Kentucky
CIGARETTE AND TOBACCO
DEPARTMENT OF REVENUE
1 7
__ __ __ __ __ __ / __ __ / __ __ __ __
PRODUCTS LICENSES
Account Number
Tax
Year
Unclassified Acquirer—Cigarettes and Tobacco Products Transporter
Check applicable box(es): Resident Wholesaler
Nonresident Wholesaler Unclassified Acquirer—Cigarettes Only Subjobber
Vending Machine Operator Tobacco Products Distributor Retail Distributor
Wholesalers and subjobbers must file a separate application for each place of business. Unclassified acquirers, transporters, and
vending machine operators are required to secure only one license. Unclassified acquirers must have a cigarette stamping location in
Kentucky.
Enter Exact Name of Business
Present License Number
Kentucky Sales Tax Permit
Name of
(if any)
Number
Business
Location of
Business
Number and Street
City
County
State
ZIP Code
If a Tobacco Products Distributor or a Retail Distributor, list all locations where tobacco products will be sold, stored, or shipped.
(Attach list if necessary.)
Mailing
Address
P.O. Box or Number and Street
City
County
State
ZIP Code
Contact Name: _______________________________
E-mail Address: _____________________________________
Other
(
)
(
)
Information
Telephone Number: __________________________________
Fax Number: ________________________________
Kentucky Revised Statute Chapter 131.610(6) requires every stamping agent and distributor to provide, and update as necessary, an electronic
mail address to the Department of Revenue for the purpose of receiving any notifications as a result of changes to the MSA directory.
The Department of Revenue will also use the e-mail address as a primary means of contacting you if questions arise from reviewing this
application, monthly returns and schedules, and to make any request for information needed for determining the accuracy of returns.
License is issued for each fiscal year, or portion, beginning July 1 and ending June 30.
Period of
License
Fiscal year ending June 30, __________________
FEIN #: __ __ – __ __ __ __ __ __ __
Type of
Individual
Partnership
Corporation
Limited Liability Corporation
Ownership
Other (describe)________________________________________________________________________________
If Corporation: Date of Incorporation: _____________________________
If Foreign Corporation: Date of Acceptance by Kentucky Secretary of State: ___________________________
Telephone Number
Name
Title/Position
Home Address
Social Security Number
(Include area code)
Names and
Addresses of
(
)
_________________________________________________________________________________________________
(
)
Owners or
_________________________________________________________________________________________________
Principal
(
)
_________________________________________________________________________________________________
Officers
(Attach list if necessary.)
If the business is located outside of the Commonwealth of Kentucky, designate a process agent who resides in Kentucky.
Name and
Name ____________________________________________________________________________________________
Address of
P.O. Box or Number and Street ________________________________________________________________________
Process Agent
City or Town ______________________________________________________________________________________
Nature of
Dealer in Cigarettes Exclusively
Wholesaler of Groceries
Business
Vendor of Other Merchandise Through Vending Machines
Dealer in Cigarettes, Tobacco Products
(Check All
Vending Machines Operated in Connection with Other Business
and Candy, etc.
Boxes That
Other (describe)_____________________________________
Dealer in Tobacco Products Exclusively
Apply)
Check applicable box(es) and insert total fee(s) on the line below.
Resident Wholesaler ..................................$500
Subjobber ............................ $500
Nonresident Wholesaler ............................$500
Transporter ........................... $ 50
Mail application and remittance to:
Unclassified Acquirer—Cigarettes Only ...$ 50
Vending Machine Operator .. $ 25
Kentucky Department of Revenue
Tobacco Products Distributor ....................$500
Retail Distributor ................ $100
Station 62
Unclassified Acquirer—Cigarettes/Tobacco Products .............................................. $500
Frankfort, KY 40619
Overnight Address:
AMOUNT OF LICENSE FEE(S).............................. $ _________________________
Account Number ___________________________
501 High Street
Frankfort, KY 40601-2103
10% Penalty (if applicable) .......................................
_________________________
Total Remittance ........................................................ $ _________________________
Make check payable to Kentucky State Treasurer.
(Complete Second and Third Page)
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