Form Tpm-5 - Stamper E-Mail Registration Form printable pdf download

Form Tpm-5 - Stamper E-Mail Registration Form

State of Connecticut

Form TPM-5

Stamper E-Mail Registration Form

(Rev. 03/06)

Complete this form in black or blue ink only and return to the Department of Revenue Services (DRS):

Department of Revenue Services

Audit Division, Excise/Public Services Subdivision

25 Sigourney Street

Hartford CT 06105

The information required by this form may also be faxed to DRS. The fax number is: 860-541-7698.

Stamper Name: ___________________________________________________________________________________________

DRS Cigarette Distributor License Number: ___________________________________________________________________

Street Address: ___________________________________________________________________________________________

City: _____________________ State: ___________________________ ZIP Code: ____________________________________

Mailing Address (if different from above): _____________________________________________________________________

________________________________________________________________________________________________________

Telephone Number: _______________________________________________________________________________________

FAX Number: _____________________________________________________________________________________________

Contact Person: __________________________________________________________________________________________

Title: ____________________________________________________________________________________________________

Web Site Address: ________________________________________________________________________________________

Stamper’s E-mail Address: _________________________________________________________________________________

Form Tpm-5 - Stamper E-Mail Registration Form