Fillable Form 336 - Tobacco Tax License Application (Page 2 of 7) in pdf

Form 336 Page 2

PArT 2: Business oWners AnD oPerATors — ConTinueD

Concerning each business owner, officer, partner, member, and other persons authorized to make purchasing decisions for this

company, answer ALL of the following questions:

Has an owner/operator of the business:

(a) Been issued a tobacco tax license in another state in his/her own name or in the name

of a corporation, LLC, LLP or other entity? .........................................................................................................

Yes

If yes, list the name of the business and state located in: ________________________________________________________

(b) Had a tobacco tax license/application suspended, revoked, refused or denied in Michigan

or in any other state?...........................................................................................................................................

Yes

If yes, name of state(s): __________________________________________________________________________________

(c) Been charged with a crime (felony or misdemeanor)? ........................................................................................

Yes

2. If the business is a corporation, LLC, LLP or other entity, has an officer, shareholder, member or partner:

(a) Been issued a tobacco tax license in another state in his/her own name or in the name

of a corporation, LLC, LLP or other entity? .........................................................................................................

Yes

If yes, list the name of the business: _________________________________________________________________________

(b) Had a tobacco tax license/application suspended, revoked, refused or denied in Michigan

or any other state? ..............................................................................................................................................

Yes

If yes, name of state(s): __________________________________________________________________________________

(c) Been charged with a crime (felony or misdemeanor)? ........................................................................................

Yes

Does an owner, officer, partner, member or any person authorized to make purchasing decisions

for this company have a financial interest in a retail business located in Michigan or elsewhere

that sells tobacco products? .....................................................................................................................................

Yes

If yes, provide the name, address and telephone number for each of those retail businesses.

_____________________________________________________________________________________________________

PArT 3: Business oPerATions

List ALL companies from which you plan to purchase cigarettes (CIG), roll your own tobacco (RYO) or other tobacco products (OTP).

(Attach additional sheets if necessary.)

noTe:

•

If importing tobacco from out of country, you MUST include a current copy of your TTB Importers Permit.

•

If, during the license year, you wish to purchase tobacco products from a company that is not listed below, you MUST

notify the department prior to doing so.