Tobacco License Questionaire / Distributor Reporting Requirements printable pdf download

Tobacco License Questionaire / Distributor Reporting Requirements

TOBACCO LICENSE QUESTIONAIRE / DISTRIBUTOR REPORTING

REQUIREMENTS

Distributors of Cigarettes

Other Tobacco Products (cigars, smoking tobacco, plug, etc)

NAME OF BUSINESS:

(ENTER LEGAL NAME OF BUSINESS)

BUSINESS (OR DBA) NAME:

(ENTER BUSINESS (OR DBA) NAME)

COMPLETE entirely and return with your license application/license renewal form and $25 annual

license fee (check or money order) in order to have your license Issued or Renewed (keep a copy for

your records).

1. What tobacco products are you going to purchase for sale?

(i.e. cigarettes (either stamped and/or unstamped), cigars, smoking tobacco, etc

2. Are you going to purchase products from a licensed Arizona Tobacco Distributor (does your source

of supply already pay the “luxury tax” to the State of Arizona)?

Yes __________

No ___________

if unsure, contact your supplier and determine if they pay the “luxury tax” and request a copy of

their current AZ Tobacco Distributor’s license for your records.

Note: Retailers ARE NOT required to obtain a tobacco license (* see note about business located in

Tucson) to sell tobacco products, providing the “luxury tax has been paid by your supplier, retain

copies of invoices for you records.

3. Where will your business be physically located, provide a physical address; phone number and

your business hours of operation include days of the week (i.e. Mon to Fri) and normal business

hours (i.e. 9 am to 10 pm)

| (

)

______|

Physical Address/

Phone Number

Days: (i.e. Mon to Fri) Hours: (i.e. 9 – 5)

5. If stamping address is different than the business address you must provide the address, phone

number and normal hours of business.

| (

)

______|

Physical Address/

Phone Number

Days: (i.e. Mon to Fri) Hours: (i.e. 9 – 5)

Have you previously been licensed as a tobacco distributor in Arizona?

Yes ____ No ______ list distributor name & license number. ___________

Note: If your business is located in Tucson, you maybe required to obtain a tobacco retailer’s license from the city

of Tucson. Contact the City of Tucson at (520) 791-4566.

Revised October 19, 2006

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Tobacco License Questionaire / Distributor Reporting Requirements

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