Form Boe-400-Ldr - Renewal Application For Distributor'S Cigarette And Tobacco Products License Page 2
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3BOE-400-LDR (S1B) REV. 3 (7-12)
SECTION II: CANCELLATION NOTICE
(complete this section only if you will not be maintaining your Distributor's Cigarette and Tobacco
Products License) You must complete Section VI and return this renewal to the BOE.
I am no longer in business. Date business discontinued:
Daytime telephone number:
Mailing Address:
SECTION III: OWNERSHIP CHANGE
(you must complete Section VI and return this renewal to the BOE)
A change in the ownership type of your business requires a new license to be issued. You can apply for accounts, licenses, and
permits using eRegistration (eReg) available on our website at eReg is also available in our field offices. Please
call our Taxpayer Information Section for assistance at 800-400-7115 (TTY:711).
I changed the ownership type of my business on:
FROM:
TO:
Daytime telephone number:
Mailing Address:
SECTION IV: BUSINESS INFORMATION CHANGES
(complete this section only if you have changes to any of the fields below)
EMAIL ADDRESS
1) NEW BUSINESS OR TRADE NAME/DBA
DAYTIME TELEPHONE NUMBER
2) NEW LOCATION OF BUSINESS (do not list PO Box or agent's address for location of business)
(
)
3) NEW MAILING ADDRESS (if different from business location; do not enter agent's address here)
DAYTIME TELEPHONE NUMBER
(
)
4) NEW AGENT/BOOKKEEPER NAME
NEW AGENT/BOOKKEEPER TELEPHONE NUMBER
(
)
5) NEW AGENT/BOOKKEEPER MAILING ADDRESS
NEW AGENT/BOOKKEEPER EMAIL ADDRESS
SECTION V: ADDITIONAL INFORMATION
If you are storing cigarettes and/or tobacco products at a California location other than your sales location, please list the
address of all storage locations (attach additional page if necessary).
SECTION VI: SIGNATURE
I affirm that the applicant (including each general partner and each person who has control as defined in California Business and
Professions Code section 22971(p)) has not been convicted of a felony under sections 30473 or 30480 of the Revenue and
Taxation Code and has not violated and will not violate or cause or permit to be violated any of the provisions of the Cigarette
and Tobacco Products Licensing Act of 2003 or any rule of the State Board of Equalization applicable to the applicant (including
each general partner and each person who has control as defined in California Business and Professions Code section 22971(p))
pertaining to the manufacture, sale, or distribution of cigarettes or tobacco products. The applicant (including each general
partner and each person who has control as defined in California Business and Professions Code section 22971(p)) also agrees
to comply with the reporting, payment, recordkeeping, and license display requirements as specified in the Cigarette and
Tobacco Products Licensing Act of 2003 under Division 8.6 (commencing with section 22970) of the California Business and
Professions Code. (If you are unable to affirm this statement, you must provide the BOE with a separate statement containing the
nature of any violation or reasons that will prevent you from complying with the requirements with respect to the statement.)
I certify that all the information provided in this application is complete, true, and accurate. I understand that any person who
asserts the truth of any material matter that he or she knows to be false, is guilty of a misdemeanor punishable by imprisonment
of up to one year in county jail, or a fine of not more than one thousand dollars ($1,000), or both the fine and imprisonment.
Note: This must be signed by an owner, partner, corporate officer, LLC member or manager, or by an authorized agent. For a
partnership, attach authorization signed by all general partners; for a corporation, attach corporate resolution; and for a
LLC, attach articles of organization which authorize the individual who signs below to certify this application. If signed
by an authorized agent, a properly completed power of attorney form must be attached to this application.
SIGNATURE
EMAIL ADDRESS
PRINT NAME AND TITLE
TELEPHONE
DATE
(
)
If you need additional information, please contact the State Board of Equalization, Special Taxes and Fees, P.O. Box 942879,
Sacramento, CA 94279-0088. You may also visit the BOE website at or call the Taxpayer Information Section at
800-400-7115 (TTY:711); from the main menu, select the option Special Taxes and Fees. Customer service representatives are
available weekdays from 8:00 a.m. to 5:00 p.m. (Pacific time), except state holidays.
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