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MDEPARTMENT CT102 I OF REVENUE License Application to Make Retail Sales of Cigarette and Other Tobacco Products To be completed by applicant when applying for a license with a city or county. FOR MUNICIPAL_ USE ONLY Apprhrans Mlnrr� otrTax Ip Number b The Minnesota Tax ID must be issued in the same E Eiceme Auk w-"-- j(7 7 7 J legal name of the licensee below_ C l ,JG6151 Ucense Number t Clip /too products will be sold (a separate license is required Period covered for each each location or vending machine): i Iv l Over Counter ❑ Through Vending Machine ❑ Both Date or Issuance , Liceraws 7 Name + Federal Employer ID [Sumter r `1 Buslhess Trade Name (dolnEbusinass as) - Daytime Phone Cotmlew Address of Busuiess Location (permit Ana>rorrl county tither Phone Number ..� f ,' T tI li, N LLM-r cityy� r state zip code Fax Number - K"MrIgAddress (f rlfff Wentthan buskiessaddmssl city State ZIP Code Email Addres, ._. . Type of legal organization (check one): L�75ole proprietor ❑ Minnesota corporation: Enter date of incorporation ❑ Partnership ❑ Out-of-state corporation-, State of incorporation a Other (describe) Are you registered to do business in Minnesota? Dyes ❑ No oCorporate officers or partners (attach a list it necessary) Noma e Address City b State ZIP Code Name l`r1Ee Address city state - - ZIP Code Its a licensed tobacco products or cigarette retailer, ) understand that- 1. 1 can purchase cigarettes only from a Minnesota distributor or subjobber who holds a license with the Minnesota Department of Revenue. 2- 1 must obtain a tobacco products distributor license if i purchase untaxed tobacco products from an out-of-state company. 3. 1 may not sell cigarettes affixed with Minnesota Native American stamps unless my retail business is located on a reservation that has a tax agreement with the State of Minnesota. 4. 1 may not purchase from or exchange cigarettes or tobacco products with another retailer. S 5- 1 must keep complete and legible cigarette and tobacco products invoices on the licensed premises, or make invoices available within one hour of request, for at least one year after the date of the purchase. 6. 1 know that the Minnesota Department of Revenue and/or law enforcement may conduct cigarette and tobacco inspections of the premises, including inspections of inventory, invoices and licenses, and I understand that a refusal to allow an inspection is grounds for revocation of my license, 7. 1 know that failure to comply with all requirements can result in criminal penalties, including the loss of cigarettes and tobacco products. p Lie ens!e swat T'iNe Print Name pate Dayime Phone CAW vqgy- Man ltv tpi 2,o7-1 q3Q�, 3 licensing AgenrsSignature Title Print Name Date PaAiroe Phone iq License applicant Submitthis form to the licensing authority along with the license application. Licensing author): Mail, email or fax to: Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146.3331. Fax: 651556.5236. Email: clgarette.tobaccoOstate.mn.us {Rev. 9/iT,