Form 2175 - Cigarette/other Tobacco Products Tax License Application - Missouri Department Of Revenue - 2003 Page 2
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IDENTIFY OWNERS, OFFICERS, PARTNERS, MEMBERS (ATTACH LIST IF ADDITIONAL SPACE IS REQUIRED.)
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO.
BIRTHDATE
HOME ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EFFECTIVE DATE OF TITLE
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO.
BIRTHDATE
HOME ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EFFECTIVE DATE OF TITLE
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO.
BIRTHDATE
HOME ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EFFECTIVE DATE OF TITLE
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO.
BIRTHDATE
HOME ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EFFECTIVE DATE OF TITLE
If you are licensed for cigarette or other tobacco products in other states, please list the state and all license numbers.
ALL CIGARETTE TAX APPLICANTS MUST COMPLETE THIS SECTION
NEW CIGARETTE WHOLESALER APPLICANTS MUST ATTACH LETTERS OF RECOMMENDATION FROM FOUR OF THE FIVE
LEADING MANUFACTURERS, I.E., BROWN & WILLIAMSON, LIGGETT & MYERS, LORILLARD, PHILIP MORRIS AND R.J.
REYNOLDS.
LIST THE BRAND NAME, TYPE, AND MODEL NUMBER OF THE STAMPING MACHINES YOU WILL USE:
CHECK THE APPROPRIATE BOX AS TO HOW YOU WISH TO PURCHASE DECALS:
CASH BASIS
CREDIT BASIS *
CASH AND CREDIT BASIS *
* MUST POST BOND FOR AMOUNT OF CREDIT DESIRED (CONTACT OUR OFFICE AT (573) 751-7163 FOR FORMS AND INSTRUCTIONS.)
ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION
I DECLARE THAT THE ABOVE INFORMATION AND ANY ATTACHMENTS ARE TRUE, COMPLETE, AND CORRECT. THE APPLICATION MUST BE SIGNED BY THE OWNER, IF THE BUSINESS IS A
SOLE PROPRIETORSHIP; BY A PARTNER, IF THE BUSINESS IS A PARTNERSHIP; OR BY A REPORTED OFFICER, IF THE BUSINESS IS A CORPORATION. THE SIGNATURE MUST BE OF THE
OWNER, PARTNER, OR OFFICER AS REPORTED ON THIS APPLICATION.
SIGNATURE
TITLE
DATE
PLEASE TYPE OR PRINT NAME
GENERAL INSTRUCTIONS
1. Cigarette wholesalers must complete the entire application. New applicants must attach letters of recommendation from four of the five leading
manufacturers. Attach all back-up documentation required for application.
2. Applicants for other tobacco products license, who are not applying for a cigarette wholesaler’s license, are required to maintain a bond in the
amount of three times the average tax liability, estimated in the case of a new applicant. There is a $500.00 minimum. Call (573) 751-5772 to
request bond forms and/or additional information.
3. Applicants applying for both cigarette and other tobacco products licenses are only required to submit one ($100.00) license fee.
Mail the original application, bond form and all required documentation to: Division of Taxation and Collection, PO Box 811, Jefferson
City, Missouri 65105-0811. Retain a copy for your records.
If you have questions or need assistance in completing this form, please call (573) 751-7163 or e-mail excise@dor.mo.gov. You may also access the
department’s web site at TDD: (800) 735-2966
This publication is available upon request in alternative accessible format(s).
MO 860-0627 (12-2003)
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