APPLICATION FOR TOBACCO SALES CERTIFICATE INDIANA ALCOHOL & TOBACCO COMMISSION 302 W. Washington Street, Rm. E114 State Form 51357 (R/7-05) Approved by State Board of Accounts, 2005 Indianapolis, Indiana 46204 Tobacco Enforcement: (317) 234-2089 Web page: http://www.IN.gov/atc STEP 1. GENERAL INFORMATION Name of Business Entity Business telephone number ( ) E-mail address - Address where tobacco products are sold (number, street & room #) City County State Zip Mailing Address (if different than business) City County State Zip DBA Check one: o Renewal Certificate number (if renewal) Certificate Expiration (if renewal) o Original application STEP 2. BACKGROUND o Yes o No Do you understand that it is against Indiana law to sell a tobacco product to someone under 18 years of age? o Yes o No Do you understand that under Indiana law access to tobacco vending machines is illegal to people under 18 years of age? o Yes o No Do you understand that under Indiana law you must post the proper tobacco signage depending on what type of tobacco vendor you are? o Yes o No Do you understand that the identification of anyone that appears under the age of 26 should be checked before selling them a tobacco product? o Yes o No o Yes o No Do you understand that cigarettes have to be sold in a pack or carton and that selling single cigarettes is illegal? o Yes o No Do you understand that the penalty for violation of certain tobacco laws can be a fine of up to $500.00 for each violation? o Yes o No Do you understand that if you sell tobacco products without a valid certificate, you may be fined up to $10,000? o Yes o No Do you understand that your tobacco certificate must be renewed each year? o Yes o No Do you understand that a new business selling tobacco may not operate within 200 feet of a public or private elementary or secondary school? o Yes o No Do you understand that the Indiana cigarette fair trade law must be followed at all times? o Yes o No Do you understand that tobacco sales certificates must be posted in accordance with Title 905 of the Indiana Administrative Code. Do you understand that valid forms of identification include the following government issued IDs: a Drivers License, a State Issued ID card, a US Passport, a US Military ID card, and a US Immigration card. STEP 3. FEE AND PAYMENT SCHEDULE There is a $200 fee for a 3 Year Certificate. You may apply in person, by mail, or online. Payment by mail may be by money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. Apply online at http://www.IN.gov/atc and pay with MasterCard or Visa. STEP 4. SIGNATURE AND AFFIRMATION I certify that this application was completed by myself. I affirm under penalty of perjury that all information provided on this form is true and correct. I understand that it is a felony under Indiana law to misrepresent or falsify any portion of this application. Signature of applicant Date signed (month, day, year) American LegalNet, Inc. www.FormsWorkflow.com