Form Tt-1 - Schedule A - Application For Cigarette Stamping Permit And Tobacco Products Tax Distributor'S License Personal Data Form
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1
2
3Commonwealth Of Virginia
Schedule A
For Offi ce Use Only
Virginia Department Of Taxation
Form TT-1
Application for Cigarette Stamping Permit
And Tobacco Products Tax Distributor’s License
Personal Data Form
•
Please read instructions before completing application.
•
Schedule A must be completed for any offi cer, director, manager, sole proprietor, partner, member, stockholder, or any other person possessing an
ownership interest of 10% or greater in the applicant, who exercises authority or control over the purchase, storage, sale or distribution of cigarettes or
other tobacco products (“OTP”), or over the compliance with any cigarette or tobacco products tax laws.
•
A completed Schedule A must also be fi led within 10 days for any person meeting this criteria after the date of the initial application.
•
After the initial approval, there is a non-refundable $100 fee for each additional background check.
•
Copy form as needed.
•
Please print or type.
Business Name
FEIN/SSN
A. Personal Information
First Name
Middle Name
Last Name
Suffi x (Sr, Jr, III)
Maiden Name (If applicable)
Date of Birth (MM/DD/YY)
Place of Birth (City, State, Country)
Social Security Number
Sex
Check the block for the racial or ethnic group with which you identify:
White (includes Arabian)
American Indian (includes Alaskans)
F
M
Black (includes Jamaicans, Bahamians and other
Hispanic (includes persons of Mexican,
Home Phone Number
Caribbeans of African but not Hispanic or Arabian
Puerto Rican, Central or South American
descent)
or other Spanish origin or culture)
(
)
Asian & Asian American (includes Pakistanis, Indians & Pacifi c Islanders)
B. Home Address - Must enter the physical location. No post offi ce boxes are allowed.
Number and Street Name
City
State
ZIP
C. Have you been a resident of Virginia continuously for the past 10 years?
Yes
No
If No, attach a list of other states in which you have resided for more than six months and include dates. Also submit a copy of a criminal
history record for each such state. Your application will not be processed until all criminal history records are received.
D. Relationship to Business
Sole Proprietor
Partner (
% )
Manager
Other, Specify
Stockholder (10% or more)
Member (
% )
Offi cer/Board Member
E. Have you ever:
•
owned or controlled, directly or indirectly, 10% or more of the ownership of a business engaged in cigarettes or OTP other than the company
listed above; or
•
been an offi cer, director or partner of a business engaged in cigarettes or OTP other than the company listed above?
Yes ( If Yes, complete below.)
No
Name of Other Business
FEIN/SSN
Address
City, State, ZIP
Dates of Participation
Name of Other Business
FEIN/SSN
Address
City, State, ZIP
Dates of Participation
Name of Other Business
FEIN/SSN
Address
City, State, ZIP
Dates of Participation
Name of Other Business
FEIN/SSN
Address
City, State, ZIP
Dates of Participation
Va. Dept. of Taxation
TT-1 W
REV 09/07
Page 1
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