Form Cg-109 - Application For Cigarette Licenses

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KANSAS DEPARTMENT OF REVENUE
FOR OFFICE USE ONLY
MISCELLANEOUS SEGMENT – CUSTOMER RELATIONS
915 SW HARRISON ST.
Val #:
TOPEKA, KANSAS 66612-1588
Web site:
Email: miscellaneous.tax@kdor.ks.gov
Phone: (785) 368-8222
Fax: (785) 291-3968
APPLICATION FOR CIGARETTE LICENSES
CHECK the box for each license that you are applying for:
(1)
Retail Cigarette/E-Cigarette
Dealer's License
$25.00 ea.
Show, Carnival, or Catering Cigarette Dealer License $50.00 ea.
Temporary Retail Cigarette License
$ 2.00 ea.
Manufacturer Salesman License
$20.00 ea.
Cigarette Vending Machine Permit
$25.00 ea.
Wholesale Salesman ID Card
$20.00 ea.
Wholesale Cigarette Dealer's License
$50.00 ea.
Lost License / Change of Location
$ 2.00 ea.
(1)
Electronic Cigarettes
________
________
Indicate year license is for
(Year)
(Year)
PART I — BUSINESS INFORMATION
1.
2.
3.
(
)
Business Name
Federal Employer ID Number
Business Telephone Number
1.a
DBA NAME / SALESPERSON
4.
Mailing Address
City
State
Zip Code
5.
Exact Location of Business
City
State
County
Zip Code
.
Type of Ownership:
6
Individual
Partnership
Corporation
LLC
Other
7. Identify Owners, Officers, and Partners (use additional sheet if necessary):
Name
Title
Home Address
Social Security Number
a.
Email address:
Percentage of Ownership
%
b.
Email address:
Percentage of Ownership
%
c.
Email address:
Percentage of Ownership
%
d.
Email address:
Percentage of Ownership
%
TOTAL AMOUNT ENCLOSED
$
.................................................................................................................................
The undersigned hereby certifies to be correct to the best of his/her knowledge and belief that all owners, partners, corporate officers and directors
are of good moral character and reputation in the community in which they reside and further have not within two (2) years preceding the filing of
this application been convicted of any felony or crime involving moral turpitude or any crime involving any law of any state or of the United States
pertaining to cigarettes or tobacco products and if so convicted, has completed the sentence, parole, or probation for any such conviction more than
two (2) years immediately preceding the date of making application.
Only owner, partner, or listed corporate officer may sign this application.
4
SIGN
HERE
Signature of Owner, Partner or Corporate Officer
Title
Date
For lost license, enclose Form CG-96 Affidavit. For change of location, enclose current license.
CG-109
—APPLICATION CONTINUES ON REVERSE SIDE—
(Rev. 6/13)

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