Form 0405-625 - Authorization Of Agent Or Designee To Purchase Cigarette Tax Stamps

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Alaska
625
Authorization of Agent or Designee to Purchase
Cigarette Tax Stamps
The licensee identified in Part I hereby authorizes the entity identified in Part II to purchase cigarette tax stamps
on its behalf. This authorization will remain in effect until the department receives the licensee’s written notice
of revocation of the authorization. The licensee understands that designation of another entity to purchase
cigarette tax stamps does not absolve the licensee of its liability to pay the amount due for cigarette tax stamps
in the time required by law.
Part I
License Authorizing an Agent or Designee to Purchase Cigarette Tax Stamps
Name
License Number
Contact Name
Mailing Address
Telephone Number
Fax Number
City
State
Zip Code
Contact Telephone Number
Contact Fax Number
Check here if you have been authorized to
Email Address
and are paying under a deferred payment plan.
Part II
Agent or Designee Authorized to Purchase Cigarette Tax Stamps on Behalf of Licensee
Name
License Number
Contact Name
Mailing Address
Telephone Number
Fax Number
City
State
Zip Code
Contact Telephone Number
Contact Fax Number
Email Address
By signing this form, the licensee understands that any cigarette tax liability arising from the purchase of cigarette tax stamps
by the Agent or Designee identified in Part II on behalf of the licensee is the sole responsibility of the licensee.
Signature of Licensee
Printed Name of Licensee
Title
Date
Department Use Only
Authorization of agent or designee to purchase cigarette tax stamps on behalf of the licensee identified in Part I is acknowledged by the
Tax Division.
Signature
Title
Date
625
Mail to: Alaska Department of Revenue, 550 W 7th Ave STE 500, Anchorage AK 99501-3555
0405-625 Rev 012/12

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