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Form Ctx-Aw - Application For A Wholesale Cigarette License Or License To Operate Cigarette Vending Machines Page 2

Agent-Jobbers, Sub-Jobbers, Vending Machine Operators

Attach additional sheets if you need to complete this application

12.

DO YOU OR ANYONE ACTING ON YOUR BEHALF OWN, LEASE OR USE ANY VEHICLES TO TRANSPORT CIGARETTES?

YES ❏

NO ❏

(If YES, please provide vehicle information for all vehicles used to transport cigarettes. You may use a CTX-A34a Form for additional space or attach a schedule.)

State of

Make & Model

Year

Color

License Plate Number

Registered to Name

Registration

13.

DO YOU HAVE CIGARETTE SALESPERSONS OR ROUTE-PERSONS REPRESENTING YOU?

YES ❏

NO ❏

(If YES, please list full names and addresses of all salespersons or route-persons representing you.)

Name

Home Address

Name

Home Address

Name

Home Address

Name

Home Address

14.

(FOR VENDING MACHINE OPERATOR ONLY) List below all locations of all vending machines (Use CTX-A34a for additional space or attach a schedule)

Name of Premises (Type of Business)

Address

15.

I affirm that this business filed all required New York City and New York State tax returns and paid all New York City and New York State tax liabilities.

Yes ❏

No ❏

If NO, provide details.

Number of Cigarette Vending Machines located as of February 1, 20____: In New York City _________________

Outside New York City________________

16.

BANK REFERENCES:

17.

The undersigned hereby certifies that the answers to the above questions are correct to the best of his/her knowledge and belief.

Name of Business

Name of Applicant

(PRINT OR TYPE)