Form 4857 - Tobacco Manufacturer'S Representative Permission List

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Michigan Department of Treasury
4857 (02-11)
Tobacco ManufacTurer’s represenTaTive perMission LisT
Issued under authority of Public Act 327 of 1993, as amended.
noTe: The manufacturer shall promptly notify the Tobacco Tax Unit, Michigan Department of Treasury, if the manufacturer’s representative is no longer
employed by the manufacturer or if there is any change in any representative’s territory in the state of Michigan, name, address, telephone number, or
vehicle make, model or license number (per Rule 205.453 for MCL 205.428).
Find additional Tobacco Tax forms online at Direct questions to the Tobacco Tax Unit by phone at (517) 636-4630 or
by fax at (517) 636-4631.
Attached this completed form to the Tobacco Tax License Application (Form 336), if applicable. Otherwise, mail to: Special Taxes Division, Michigan
Department of Treasury, P.O. Box 30474, Lansing MI 48909-7974.
parT 1: ManufacTurer DaTa
Manufacturer Name
FEIN or MI Account Number
Michigan Territory Serviced
License Year
parT 2: represenTaTive DaTa
— Attach additional pages if necessary.
Representative Name
Contact Phone Number
Street Address
Driver’s License Number
City
State
ZIP Code
License Plate Number
Counties in Territory
Other States in Territory
Representative Name
Contact Phone Number
Street Address
Driver’s License Number
City
State
ZIP Code
License Plate Number
Counties in Territory
Other States in Territory
Representative Name
Contact Phone Number
Street Address
Driver’s License Number
City
State
ZIP Code
License Plate Number
Counties in Territory
Other States in Territory
parT 3: cerTificaTion
Authorized Signature for Manufacturer
Date
Authorized Signer’s Name (Print or Type)
Authorized Signer’s Contact Number

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