Form Cig Efo00146 - Idaho Cigarette And Tobacco Tax Permit Application

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CIG
IDAHO CIGARETTE AND TOBACCO TAX PERMIT APPLICATION
EFO00146
06-02-11
For State Use Only
IDAHO STATE TAX COMMISSION
800 PARK BOULEVARD, PLAZA IV
P.O. BOX 36
BOISE, IDAHO 83722
(208) 334-7660
(800) 972-7660 (toll free)
Instructions are on pages 1 and 2.
1. Type of business
___Sole Proprietor
___Partnership
___S Corporation
___Corporation
___Limited Liability Company
2. Business activity
___Tobacco Distributor
___Cigarette Manufacturer/Importer
___PACT Act Registrant
___Cigarette Wholesaler
3. Purpose of application
___New Business
___New Location
___Change in "Doing Business As" Name
___Change in Partners or Shareholders ___%
5. Legal Business Name
4. Federal EIN
6. Social Security Number
7. Doing Business As(DBA) Name
8. Mailing Address
Street Address or PO Box
City
State
Zip Code
9. Business Locations
City
Zip Code
Street Address
State
10. Mailing Address
Street Address or PO Box
City
State
Zip Code
for Report Forms
11. Contact Person
12. Telephone Number
13. Tax Year End
14. Have you ever had an Idaho tobacco or cigarette permit? Yes
No
If yes, what year was it issued?
Business Name
Permit Number
16. Date you began or will begin selling cigarettes in Idaho
15. Date you began or will begin selling tobacco in Idaho
17. Will you stamp cigarettes?
Yes
No
If yes, you must attach proof of your bond.
If no, from whom will you purchase stamped cigarettes?
18. List (a) owner, spouse, (b) partners or (c) corporate officers.
Social Security Number or EIN
Name
Address
IF YOU ARE APPLYING FOR A PERMIT AS A CIGARETTE WHOLESALER OR CIGARETTE MANUFACTURER/IMPORTER, YOU MUST ATTACH A
$50 PERMIT FEE
CERTIFICATION: I agree to comply with reporting, payment, recordkeeping, and license display requirements. I certify that I am authorized as an
owner, partner, corporate officer, or representative to sign this document and that the statements made are correct to the best of my knowledge. I also
certify that I will comply with the Idaho Tobacco Master Settlement Agreement Complementary Act and its subsections.
Date
Signature
Title

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