Form 70-014 - Application For Iowa Retail Cigarette / Tobacco Permit printable pdf download

APPLICATION FOR IOWA RETAIL CIGARETTE / TOBACCO PERMIT

For period ______________________ , 20 ____ through June 30, 20 __

Please mail this completed application to your local jurisdiction. If you have questions,

PLEASE TYPE OR PRINT LEGIBLY

call your city clerk (within city limits) or your county auditor (outside city limits).

I/We hereby make application for a retail permit to sell cigarettes and tobacco products:

BUSINESS INFORMATION

Name of Business/DBA: ___________________________________________________________________

Location Address (Must Have): _____________________________________________________________

Mailing Address: __________________________________ City: ___________________ State/Zip: ______

Type of Sales:

Vending Machine

Over-the-counter

Telephone Number ( ____ ) _____________

Type of Retail Establishment:

has vending machine that assembles cigarettes

bar

convenience store - with gas

convenience store - no gas

drug store

gas station

grocery

hotel/motel

liquor store

restaurant

tobacco store

other ______________

Cigarettes must be sold at the minimum price set by the State of Iowa. Obtain a current copy from the Iowa

Department of Revenue Web site at or from TaxFax at 1-800-572-3943 (enter form number 71023).

ONLY APPROVED BRANDS OF CIGARETTES OR ROLL-YOUR-OWN PRODUCTS MAY BE SOLD IN IOWA

Any brand not on the list is contraband. In addition, all cigarettes sold in Iowa must have an Iowa Cigarette Tax Stamp

affixed to each package. Any violation of contraband or non-Iowa cigarette tax stamped package is subject to seizure and

penalties under the provisions of Iowa Code 453A and 453D.

The list of approved brands is always current at /business/CigTobIndex.html and is called

IOWA DIRECTORY OF CERTIFIED TOBACCO PRODUCTS MANUFACTURERS — THEIR BRANDS AND BRAND

FAMILIES

Go to and sign up for the Cigarette/Tobacco eList (listserv).

You will receive an e-mail every time the approved list changes or the minimum price changes.

LEGAL OWNER INFORMATION

Type of Ownership:

Individual

Partnership

Corporation

LLC

LLP

Legal Owner: ____________________________________________________________________________

(Name of Individual, Partnership, Corporation, LLC, or LLP)

Mailing Address: _________________________________________________________________________

City: _________________ State: ____________ Zip: _________ Ph. Number: ( _____ ) _______________

Fax Number: ( ___ ) ________________ E-mail Address: ________________________________________

If application is approved and permit granted, I/we do hereby bind ourselves to a faithful observance of the

laws governing the sale of cigarettes and tobacco products.

SIGNATURE OF OWNER, PARTNER(S), OR CORPORATE OFFICIAL

Name (please print): __________________________ Name (please print): ___________________________

Signature: __________________________________ Signature: ___________________________________

Date: ______________________________________ Date: _______________________________________

FOR OFFICE USE ONLY

FOR CITY CLERK/COUNTY AUDITOR ONLY

PLEASE SEND COMPLETED COPY TO THE IOWA

Amount Paid: _____________

DEPARTMENT OF COMMERCE,

New

Date Issued: ______________

ALCOHOLIC BEVERAGE DIVISION

Renewal

Permit #: _________________

Name of Issuing City or County ___________________

70-014a (05/30/12)

Form 70-014 - Application For Iowa Retail Cigarette / Tobacco Permit

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