Form Tb-84 - Tobacco Products Application For Distributor'S License
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1KANSAS DEPARTMENT OF REVENUE
MISCELLANEOUS TAX
915 SW HARRISON ST.
TOPEKA, KANSAS 66612-1588
Web site:
Email: miscellaneous.tax@kdor.ks.gov
Phone: (785) 368-8222
Fax: (785) 291-3968
FEE:
$25.00
TOBACCO PRODUCTS
APPLICATION FOR DISTRIBUTOR’S LICENSE
For Office Use Only
License No. __________________
Year _______________________
Issue Date ___________________
1. _______________________________________________________________________________________
(Name here must be same as on bond)
2. Exact location where Tobacco Products will be distributed:
_______________________________________________________________________________________________________
(Street Address)
(City)
(County)
(State)
(Zip Code)
3. Mailing address if different from No. 2:
_______________________________________________________________________________________________________
(Street Address)
(City)
(County)
(State)
(Zip Code)
S
S
S
S
4. Type of ownership:
Individual
Partnership
Corporation
Other
5. If you plan to sell tobacco over the internet, telephone or via mail order, please provide your email or web page address
______________________________________________________________
6. The full and correct name of applicant (if partners, state name and address of each; if corporation, list officers and their full titles.
List and attach additional names on a separate sheet.)
Name
Title
Home Address
Social Security Number
Email address:
Percentage of Ownership
%
Email address:
Percentage of Ownership
%
Email address:
Percentage of Ownership
%
Email address:
Percentage of Ownership
%
7. Business Telephone Number (________)______________________
8. Employer Identification Number (EIN) _________________________
Applicant further states that he will conduct this distributor’s tobacco products business in compliance with the Kansas Tobacco
Products Tax Law and Regulations.
SIGNED
TITLE
DATE
(Signature of owner, partner or corporate officer)
NOTE:
No license will be issued unless application contains complete required information and is properly executed, and supported by a
bond accepted by the Director of Taxation.
TB-84
(Rev. 6/13)
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