Form Cig 41 - Application For Wholesale Cigarette Dealer'S License
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CIG 41
Rev. 8/13
P.O. Box 530
Columbus, OH
43216-0530
Application for Wholesale Cigarette Dealer’s License
For the period from
, 20
to
, 20
Ohio Revised Code (R.C.) section 5743.01 defi nes “wholesale dealer” to include “only those (1) persons who bring in or
cause to be brought into this state unstamped cigarettes purchased directly from the manufacturer, producer or importer of
cigarettes for sale in this state, but does not include persons who bring in or cause to be brought into this state cigarettes with
respect to which no evidence of tax payment is required thereon, as provided in R.C. section 5743.04; (2) persons engaged
in the business of selling cigarettes to others for the purpose of resale.”
1. Name of dealer*
2. Trade name (if other than above)
3. FEIN
Social Security number
Date
Fee
$
*(If sole owner, print individual’s full name; if partnership, print full names of all partners; if corporation, print corporation’s
name and Ohio corporation charter number. If a foreign corporation, give certifi cate number issued by secretary of state
authorizing transaction of business in Ohio. R.C. section 1703.01 et seq.)
4. Check whether dealer operates as
Sole owner
Partnership
Corporation
Fiduciary
Association
LLC
LLP
Other
If corporation, list below the titles, names, addresses and Social Security numbers of all corporate offi cers or association
offi cers or partners.
Title
Name
Address
Social Security no.
Federal Privacy Act Notice
Because we require you to provide us with a Social Secu-
5703.057 and 5747.08 authorize us to request this infor-
rity number, the Federal Privacy Act of 1974 requires us
mation. We need your Social Security number in order to
to inform you that providing us with your Social Security
administer this tax.
number is mandatory. Ohio Revised Code sections 5703.05,
5. Applicant is engaged in the business of selling cigarettes to others for purposes of resale from the following place of
business. Applicant does not sell cigarettes both as a retail dealer and as a wholesale dealer from the place of
business listed below.
Street
City
State
ZIP
License no. assigned
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