Fill and Sign the Section 5 Medical Certificate Bpadcab Form 2 Padca Co

Clear Form APPLICATION FOR DISTRIBUTOR / WHOLESALER LICENSE FOR DEPARTMENT OF REVENUE USE ONLY Date received BIN Cigarette license number Tobacco license number Cigarette distributor Tobacco products distributor • You must also complete the back of this form. Date license issued Approved by Cigarette wholesaler Business name Business registry number Federal employer ID number (FEIN) State ZIP code Physical street address City County Mailing address (if different from above) City State ZIP code Telephone number Physical location of business records City State ZIP code Telephone number Contact person Date business started ( Individual Partnership Corporation Names of owners, partners, shareholders, or corporation officers: Street address Name ) ( ) ( ) Fax number for business records Telephone number Type of organization ( ) S Corporation City, state, ZIP code Other: ____________________ Social Security number Employer status Are you an employer? Yes (nonexempt) If yes, you must provide: No (exempt*) WCD seven-digit compliance number OR name of carrier and policy number: _________________________________________ *All-family business may be exempt form workers’ compensation. Contact the Workers’ Compensation Division to determine eligibility, 503-947-7815. Nature of business Manufacturer Common carrier Wholesaler Within Oregon Internet sales Distributor Retailer Importer Outside Oregon Other: ______________________ Source of product supply Manufacturer’s warehouse stock Imported direct from outside Oregon Manufactured in Oregon From other licensed distributors Cigarette tax stamps Method of payment: Cash or Method of shipment: Pick-up or Deferred payment (requires deposit of a bond) Courier: Name _________________________  Courier account no. _____________ Average number of cigarettes (with Oregon stamps) to be distributed during the year: _______________________ Contact person’s name and telephone number: ____________________________________________________________________ 150-105-001 (Rev. 12-09) Mail completed application to: Cigarette/Tobacco Tax Oregon Department of Revenue PO Box 14630 Salem OR 97309-5050 Additional information on the back ADDITIONAL INFORMATION REQUIRED FROM APPLICANTS What is the nature of your business that requires an Oregon license? In what area (cities) do you plan to distribute in Oregon? List the name, address, and telephone number of your suppliers: (attach additional pages as necessary) 1. 4. 2. 5. 3. 6. List each manufacturer’s name and the warehouse address from which you receive your supply: (attach additional pages as necessary) Manufacturer’s name Warehouse address City, state, ZIP code Identify other licenses issued to you for cigarette and tobacco products for any other state: (attach additional pages as necessary) Type of license (cigarette, tobacco products, etc.) State Will you use Oregon cigarette tax stamps on products that you distribute?   Yes   No. If yes, explain how and where you will affix the stamps for distribution. Does the business being conducted violate any Oregon law?   Yes   No Have you (applicant), or any other person listed on this application, ever been denied a permit, license, or other authorization to engage in any business to manufacture, export, or import tobacco products by any government agency (federal, state, local, or foreign), or had such permit, license, or other authorization revoked, suspended, or otherwise terminated?   Yes   No. If yes, you must explain. Consent to search for contraband product For the purpose of enforcing Oregon’s cigarette tax and anti-contraband cigarette laws, I hereby consent to the inspection and examination by the Oregon Department of Revenue and its authorized agents of any books, records (including Oregon cigarette tax stamps), receipts, invoices, equipment relating to cigarettes; cigarette packs, cigarette cartons; or any other storage container designed or used to store cigarettes or any other pertinent document or equipment related to the sale, purchase, storage, tax stamp application, or transportation of cigarettes. Federal Privacy Act Information Under the general authority of OAR 150-305.100, the Social Security numbers of all company officers of distributorships must be included in the application for a distributor’s license. This information is to be used primarily by the Oregon Department of Revenue for identification and compliance purposes in the administration of the Oregon Cigarette Tax Act and the Oregon Tobacco Products Tax Act. Oregon law permits disclosure of such information to governmental units outside Oregon, which also tax tobacco products and which grant reciprocal rights. Signing this application acknowledges awareness of the requirements of the Jenkins Act (Title 15, U.S.C. Sect. 375 et. seq.). This act requires distributors to file reports with the taxing authority of the state where cigarettes are shipped to persons other than another licensed distributor. The report must include the total number of cigarettes shipped, and the complete name and address of the person receiving the cigarettes. I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document and to the best of my knowledge, it is true, correct, and complete. Signature 150-105-001 (Rev. 12-09) Title Social Security number Date