Form Tt-1 - Virginia Application For Cigarette Stamping Permit And Tobacco Products Tax Distributor'S License Page 2

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Business Name

FEIN/SSN

H. Business Activities

Describe Primary Business Activity

Check All Boxes That Apply

Purchase products (unstamped cigarettes and/or OTP) directly from the manufacturer. Attach list of manufacturers, including names,

complete addresses and telephone numbers.

Purchase products from licensed distributors or stamping agents. Attach a list of such entities, including names, complete addresses and

telephone numbers.

Purchase OTP from distributors that are not located in or licensed in Virginia. Attach a list of such distributors, including names, complete

addresses and telephone numbers.

Operate retail stores or place on consignment where cigarettes and/or OTP are sold.

Buy and/or sell cigarettes and/or OTP on the internet. Attach a list of the Web-site addresses.

I. TT-1 Schedule A Forms Attached

A Schedule A must be completed for any off cer, director, manager, sole proprietor, partner, member, stockholder, or any other person possessing an

ownership interest of 10% or greater in the applicant, who exercises authority or control over the purchase, storage, sale or distribution of cigarettes

or OTP, or over the compliance with any cigarette or tobacco products tax laws. See instructions for additional information. Li st below each individual

for whom a Schedule A has been completed. Use additional sheets, if needed.

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

First Name

Middle Initial

Last Name

Suff x (Sr, Jr, III)

J. Individuals Not Requiring a Completed Form TT-1 Schedule A

List any of f cer, director, manager, sole proprietor, partner, member, stockholder, or any other person possessing an ownership interest of 10% or

greater in the applicant who is not listed in Section I. Use additional sheets, if needed. See instructions for additional information. The Department of

Taxation must approve any exemptions from the criminal history check.

First Name

Middle Name

Last Name

Suff x (Sr, Jr, III)

Position

Explanation

First Name

Middle Name

Last Name

Suff x (Sr, Jr, III)

Position

Explanation

Are you current with all Virginia tax return f lings and payments?

Yes

No If No, explain:

Have you operated a cigarette or OTP business in states other than Virginia?

Yes

No If Yes, list state(s) and permit number(s):

Have you ever had a cigarette and/or OTP permit or license denied, suspended or revoked in any state?

Yes

No If Yes, explain:

N. Declaration and Signature

I understand that the information I submit herein will be relied upon by the V irginia Department of Taxation and a false statement or misrepresentation

may constitute cause for the disapproval of the application or revocation of any license for which this application is submitte d . I aff rm that statements

made herein are true and if any change occurs prior to the receipt of the license, I will notify the V

irginia Department of Taxation by registered or

certif ed mail within 48 hours. If a change occurs after receipt of the license, I understand that I must advise the Department prior to the occurrence

of any change of ownership and/or location. The Department must be notif ed within 10 days of all other changes.

The application must be signed by the owner, if the business is a sole proprietorship; by a partner, if the business is a partnership; or by a

reported ofﬁ cer, if the business is a corporation. The signature must be of the owner, partner, or ofﬁ cer as reported on this application.

Signature

Title

Date

Print Name

Telephone

(

)

Va. Dept. of Taxation

TT-1 W