Form Cg-109 - Application For Cigarette Licenses Page 2

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PART II — RETAIL CIGARETTE / E-CIGARETTE DEALER'S LICENSE
Enclose a list of names and addresses of each wholesaler from whom you purchase your cigarettes/e-cigarettes.
Do you make retail sales of motor vehicle fuels or special fuels?
No
Yes If yes, you must also have a Kansas Motor Fuel
Retailers License. Complete and submit an application, Form MF-53, for each retail location.
Name of company/corporation with whom you have a fuel supply agreement/retailing agreement and make retail sale of cigarette and
tobacco products:
(e.g., Shell, BP, Phillips 66, Conoco). ________________________________________________________________________
PART III — CIGARETTE VENDING MACHINE OPERATOR'S MASTER LICENSE & VENDING
MACHINE PERMITS
PLEASE ENCLOSE CG-83 SEPARATE PAGE LISTING MACHINE BRAND NAME AND SERIAL NUMBER OF EACH
MACHINE.
In addition to the Master License (no fee), a vending machine permit is required for each vending machine in operation. Vending
machine permits are $25.00 each for a two-year calendar period.
Enclose a list of names and addresses of each wholesaler from whom you purchase your cigarettes.
Number of Permits
X
$25.00
=
$
0
PART IV — WHOLESALE CIGARETTE DEALER'S LICENSE
Each application must be accompanied by a $1,000.00 Wholesale Cigarette Dealer's License Bond. Please complete and return the
enclosed bond form CG-106 with this application. Your salesman must also obtain a wholesale salesman ID card. See Part VI.
For additional information on obtaining a Wholesale Cigarette Dealer's Credit Bond please contact this office by writing to
Miscellaneous Tax – Customer Relations, 915 SW Harrison St., Topeka, Kansas 66612-1588 or call (785) 368-8222 or email
Miscellaneous.Tax@kdor.ks.gov
PART V — SHOW, CARNIVAL, OR CATERING CIGARETTE DEALER'S LICENSE
PLEASE ENCLOSE SEPARATE PAGE LISTING FOR ALL LOCATIONS WHERE THIS LICENSE IS TO BE USED.
(PERTAINING TO SHOW, CARNIVAL, OR CATERING CIGARETTE DEALER'S LICENSE ONLY)
CAUTION: If this license will be used at places other than listed, advance notice of designated temporary locations where cigarettes
will be sold must be furnished to the Kansas Department of Revenue.
Enclose a list of names and addresses of each wholesaler from whom you purchase your cigarettes.
PART VI — MANUFACTURER SALESMANS CIGARETTE LICENSE OR WHOLESALE SALESMAN
ID CARD
(Enclose a separate sheet with a list of names and addresses if more the one salesman)
Name of Salesperson
Address of Salesperson
Name of Supervisor
Address of Supervisor
X
Telephone Number
SIGNATURE OF SUPERVISOR
This license is non-transferable but is replaceable upon loss of original license for a $2.00 fee.

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