Step 1 of 8 12% Tell Us About YourselfThis lets us get to know you better. This is the name of the person filling these forms out and this will be the contact that we remain in contact throughout the licensing application process. * is a required fieldName* First Last Email* Phone Number* Tell Us About How You Will Sell ProductsTell us how you sell your products, who you are selling to, what kind of products you are selling, and what states you will be selling these products. The price of your application is determined from the number of states you want to apply for. * is a required fieldWho are you selling your products to?*End-UserRetailerSelect all that applyWhat Types of Products will you be selling?*CigarettesCigarsOTPSelect all that applyWhat States will you be selling in?*All StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificSelect all that apply. Based on this answer, a fee will be calculated for the application, $50 times the number of states selected. Tell Us More About Your BusinessTell us more about how you have set up your business and how you do business. * is a required fieldCompany Name*Company Phone Number*Company Email Address* Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Federal Employment Identification Number (FEIN)?*Do You Work with a Surety Company?*YesNoWhat is the Name of your Licensed Surety Company?*What type of Corporation are you setting your business up under?*LLCC-CorpS-CorpSole ProprietorWhy are you applying?*New ApplicationAdditional LocationPurchase Old BuinsessChange of Address Tell us about the people that own your companyTell us about the people that will manage your stores, those member(s) can include you if you plan on managing one or more of the stores. * is a required fieldEnter Store Owner Information Title/Position Name Stock or Ownership % Edit Delete There are no Owners. Add Owner Tell us about other key people associated with the CompanyIt is possible that fingerprints may need to be gathered for some of the partners below. This information gives us an idea of how partners interact with your business. * is a required fieldAre there any persons or entities not disclosed who derive revenue from the business?*YesNoIf yes, please explain.*Are there any persons or entities not disclosed that have the right to receive revenue based on a contractual relationship related to the control of the sale of retail tobacco products?*YesNoIf yes, please explain.*Are there any persons or entities not disclosed who have a right to a percentage payment from the proceeds of the business pursuant to the lease?*YesNoIf yes, please explain.*Are there any persons or entities not disclosed who have guaranteed or co-signed a loan?*YesNoIf yes, please explain.* Distributor & Supplier InformationTell us about the distributors and suppliers that you plan on sourcing your products from.Enter Distributor & Supplier Information Address Edit Delete There are no Distributors & Suppliers. Add Distributor & Supplier Banking InformationTell us about how your business will interact with financial and banking institutions.Enter your Banking Information Address Edit Delete There are no Entries. Add Entry Pay For Your ApplicationsPay for your applications. Once you have paid for your applications, the Tobacco Tax Refund Team will get started immediately on preparing your applications and we will let you know if we have any additional questions.State Total Price: $100.00 Quantity: Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.
