CT100
2012-13
License Application for Cigarette Distributors and Subjobbers
Check license applied for:
New application
Renewal
Business legal name
Daytime phone
Minnesota tax ID number
Doing business as
Federal ID number
Street
County
Email address
City
State
Zip code
Fax number
Type of Business
Individual
Partnership or association
Corporation
State of incorporation
Date of incorporation
Corporate officers, partners or members of association (attach a list if necessary)
Name
Title
Social Security number
Address
City
State
Zip code
Name
Title
Social Security number
Address
City
State
Zip code
Name
Title
Social Security number
Address
City
State
Zip code
Name
Title
Social Security number
Address
City
State
Zip code
Your application cannot be processed without answers to the following questions.
All applicants
1 Do you acquire cigarettes for the purpose of sale to retailers or other persons for resale? . . . . . . . . . . . . . . .
Yes
No
2 Are any of these products acquired before Minnesota tax is paid on them? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
3 Have you ever been convicted of a cigarette or tobacco crime? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
4 Have you ever had a license revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
5 Will you be making sales on a Minnesota reservation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Cigarette subjobbers only
6 Do you acquire tax paid cigarettes for the primary purpose of resale to retailers? . . . . . . . . . . . . . . . . . . . . . .
Yes
No
7 Is your principal business the operation of vending machines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Cigarette distributors only
8 Do you sell or purchase “fee-brand” cigarettes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
All applicants: You must complete the reverse side. Incomplete applications will be returned to you.
(Rev. 1/12)