Form Cg-83 - Cigarette Vending Machine Listing

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KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS – MISCELLANEOUS SEGMENT
915 SW HARRISON ST.
TOPEKA, KANSAS 66625-5000
Phone: (785) 368-8222
Fax: (785) 291-3968
CIGARETTE VENDING MACHINE LISTING
_________________________
_______________________________
____________________ _____________
Name of Company
Address
City
State
______________
______________________
_____________
______________
No. of Machines
Phone Number
Zip Code
Operator License
Number
Machine Brand Name
Machine Serial #
DBA Name
Location of Machine
County
Current Permit #
______________________________________
_____________________________
Signature
Date
CG-83
(Rev. 3/10)

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