Form Mt-202 - Application For A License As A Wholesale Dealer Of Tobacco Products Or An Appointment As A Distributor Of Tobacco Products
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4MT-202
For office use only
New York State Department of Taxation and Finance
Application for a License as a
(6/08)
Wholesale Dealer of Tobacco
Products or an Appointment
as a Distributor of Tobacco Products
Tax Law — Article 20
Read Form MT-202-I, Instructions for Form MT-202, carefully before completing this application. For
additional requirements, see Form MT-202-C, Checklist for Form MT-202. Attach additional sheets if
necessary to fully answer all questions. No fee required. Subject to renewal every 3 years.
Mark an X in the appropriate box(es) for which you are applying
.
(see instructions for definitions)
Distributor of tobacco products
Wholesale dealer of tobacco products
Print or type
1 Legal name
Telephone number
(
)
2 Trade name (if different from line 1)
3 Address of principal place of business
City
State
ZIP code
4 County
(number and street)
5 Type of business organization:
Individual
Partnership
Corporation
Other
(specify):
6 Tobacco products related activities
(mark an X in all the boxes that apply)
Manufacturer (roll cigars)
Importer
Distributor located in New York State
Wholesaler
Exporter
Out-of-state distributor
Retailer
Tobacco products vending machine operator
Other
7 Mailing address
City
State
ZIP code
(if different from line 3)
8 a. Federal employer identification number (EIN) b. Other federal EIN, if any
9 Date you began or expect to begin business in New York State
10a List owners, officers, directors, partners, shareholders, or sole proprietor and all responsible persons
.
(see instructions; attach additional sheets if necessary)
Name
Social security number (SSN)
Percentage of ownership
Home/cell phone number
(
)
Home address (number and street)
City
State
ZIP code
Title
Name
SSN
Percentage of ownership
Home/cell phone number
(
)
Home address (number and street)
City
State
ZIP code
Title
Name
SSN
Percentage of ownership
Home/cell phone number
(
)
Home address (number and street)
City
State
ZIP code
Title
Name
SSN
Percentage of ownership
Home/cell phone number
(
)
Home address (number and street)
City
State
ZIP code
Title
Name
SSN
Percentage of ownership
Home/cell phone number
(
)
Home address (number and street)
City
State
ZIP code
Title
10b All other owners each hold 10% or less (less than 25% if 4 or fewer shareholders) of the voting stock in the company together totaling ......
%
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