Form Otp-901 - Application For Other Tobacco Products Distributor'S License Page 2

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Audit Information:

Location Where Records Will Be Available For Audit:

Phone Number of Location Of Audit Records:

Phone Number of Business Location:

Indicate Address of Each Location In Which You Have Other Tobacco Products in Storage

Location

OTP License Number

Indicate Name, Address, Phone Number and Estimated Annual Purchases from Whom You Currently Purchase and/or Expect to Purchase Other Tobacco Products: (A

Computer Generated List Which Includes All Requested Information Will Be Accepted)

Supplier’s Name

Address

Phone Number

Estimated Annual Purchases

TOTAL:

If Necessary Attach Additional List.

Does Your Company Expect to Sell Other Tobacco Products Into Another State?___________________________________________________________________

List States: _________________________________________________________________________________________________________________________

Today’s Date

I declare under penalties of perjury that the information contained in this application and any attachments is

true, correct and complete to the best of my knowledge and belief.