Form Boe-400-Eti - Application For Registration - Excise Taxes Page 2
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2BOE-400-ETI (BACK) REV. 1 (9-00)
10. NAMES OF BANKS, SAVINGS AND LOANS, CREDIT UNIONS (business/personal)
ADDRESS
ACCOUNT NUMBER
TYPE OF ACCOUNT
11. BUSINESS RECORDS WILL BE MAINTAINED AT:
SECTION III: REQUIREMENTS BY CATEGORY
(complete only the category that pertains to the respective permit/permit for which you are applying)
CIGARETTE AND TOBACCO PRODUCTS TAX LAW INFORMATION REQUIRED
1. NATURE OF BUSINESS:
a.
Cigarette manufacturer:
d.
Cooperative association
h.
Cigarette wholesaler
Within California
e.
Vending machine operator: Number
i.
Tobacco products distributor
of cigarette machines
Outside California
j.
Tobacco products wholesaler
b.
Cigarette distributor
f.
Common carrier
c.
Chain store
g.
Persons authorized to sell cigarettes
on common carriers
2. SOURCE OF CIGARETTE/TOBACCO PRODUCTS SUPPLY (check applicable source):
Manufacturers’ warehouse stock in California
Licensed wholesalers
Imported direct from other states
Manufactured in California
Licensed distributors
Imported direct from outside the country
3. NAME OF MAJOR SUPPLIERS
ADDRESS
PRODUCTS PURCHASED
INTEGRATED WASTE MANAGEMENT FEE INFORMATION REQUIRED
1. OWNER NAME IF DIFFERENT THAN OPERATOR
2. SWIS NUMBER
EMERGENCY TELEPHONE USERS SURCHARGE INFORMATION REQUIRED
1. CERTIFICATE OF PUBLIC CONVENIENCE NUMBER (ISSUED BY CA PUBLIC UTILITIES COMMISSION)
U __________ C
2. BILLING AGENT (if applicable)
3. TYPE OF SERVICE OFFERED
Local exchange
Long distance
Long distance reseller
Cellular
Other (please explain)
ENERGY RESOURCES SURCHARGE INFORMATION REQUIRED
1. Will you be generating and reselling electrical energy?
Yes
No
2. Will you be purchasing electrical energy without the State Energy Surcharge from the federal government?
Yes
No
3. Other (please explain)
SECTION IV: CERTIFICATION
I hereby certify that the statements contained in this application are correct to the best of my knowledge
and belief, and that I am duly authorized to sign this application.
SIGNATURE
TITLE
NAME (typed or printed)
DATE
FOR BOARD USE ONLY
FURNISHED TO APPLICANT
REPORTING BASIS
Pamphlet 4
RETURNS/FORMS
Pamphlet 5
RECEIVED BY:
Pamphlet 10
SECURITY
Pamphlet 11
APPROVED BY
Pamphlet 15
Pamphlet 16
REMOTE INPUT DATE
BY
Pamphlet 20
Pamphlet 39
DATE
PERMIT/LICENSE ISSUED
Pamphlet 69
PRINT
CLEAR
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Parent category: Financial