Form Tob 555 - Application For Tobacco License
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2TOB
APPLICATION FOR TOBACCO LICENSE
555
COMPLETE THIS FORM AND RETURN IT WITH YOUR REMITTANCE. ALL QUESTIONS MUST BE ANSWERED COMPLETELY FOR YOUR
REMITTANCE TO BE PROPERLY CREDITED. This license may be revoked upon the failure to pay a tax or taxes, or for the violation of any rule
or regulation that the commissioner has authorized (including the sale of illegal cigarettes). For additional information regarding this
application you may call Taxpayer Services between 8:00 a.m. and 4:30 p.m. (CT), Monday through Friday, holidays excepted. Please see the
back of this notice for our local offices and phone numbers.
BUSINESS MAILING ADDRESS
BUSINESS NAME AND EXACT LOCATION
STREET OR ROUTE, P.O. BOX #
NAME (GIVE TRADE NAME AT THIS LOCATION)
STREET, HIGHWAY, COMMUNITY (DO NOT USE P.O. BOX #)
CITY
STATE
ZIP CODE
BUSINESS TELEPHONE NUMBER
FAX NUMBER
CITY
COUNTY
STATE
ZIP CODE
Area Code (
)
Area Code (
)
BUSINESS E-MAIL ADDRESS
EFFECTIVE DATE
FEIN/SSN
CONTACT PERSON
CONTACT E-MAIL ADDRESS
FAX NUMBER
PHONE NUMBER
Area Code (
)
Area Code (
)
Does Applicant control, possess, or maintain a cigarette rolling machine at a retail establishment? Yes
No
(A)
If yes, how many machines? _____________________________
Did Applicant receive notification of the law relative to cigarette rolling machines (Tenn. Code Ann.
(B)
67-4-1033) from the seller or lessor prior to purchase or lease of the rolling machine(s).
Yes
No
(C)
Does Applicant intend to affix tax stamps to cigarettes?
Yes
No
(D)
Applicant is aware of Tennessee's "complementary legislation", T.C.A. Section 67-4-2601 et seq. Yes
No
Applicant intends to comply with T.C.A. Section 67-4-2601 et seq.
Yes
No
(E)
(F)
Applicant will purchase only untaxed Other Tobacco Products from outside Tennessee
Yes
No
Former owner of the business was (if within 3 years) ________________________________________________ .
(G)
(H)
Former trade name of business was (if within 3 years) _______________________________________________ .
1. Check Type of
A. Tobacco Distributor - $100
Tobacco License:
B. Wholesale Dealer & Jobber - $200
C. Manufacturing Distributor - $200
NOTE: Please check appro-
D. Tobacco Manufacturer's Warehouse - $200
priate box at right and enter
E. Cigarette Rolling Machine Operator - $500 per machine ..........
(1)
$ _ _________________
amount on line provided.
$
(2)
__________________
2.Penalty - Enter the amount of penalty as calculated in the instructions ......................................
(3) $
__________________
3.Total Amount Due..................................................................................................................
MAKE CHECK PAYABLE TO:
TENNESSEE DEPARTMENT
OF REVENUE
FOR OFFICE USE ONLY
Under penalties of perjury, I declare that the statements in this
application are true and correct to the best of my knowledge
Acct. Number ____________________
and belief. This application applies only to the specified busi-
ness and location listed hereon.
Authorized Signature & Title
INTERNET (12-12)
RV-R0010501
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