INDIANA DEPARTMENT OF REVENUE P.O. BOX 901 INDIANAPOLIS, IN 46206-0901 OTP-901 R3/ 10-07 FOR OFFICE ONLY OTP This form must be submitted 30 days prior to: a) the expiration of your current license or, b) the date you begin your business You may not do business without your certificate. APPLICATION FOR OTHER TOBACCO PRODUCTS DISTRIBUTOR’S LICENSE Renewal New Certificate Applicant’s Name - Enter individual’s, partnership’s, or corporation’s name Federal ID Number Business/Trade Name (if different than above) Telephone Number Mailing Address (Street or P.O. Box Number) City or Town County State Zip Code Location Address of Business (if different than above) City or Town County State Zip Code Type of Ownership: Sole Proprietorship Partnership Owner’s Social Security # Corporation If Corporation: Date of Incorporation:___________________________________ If Foreign Corporation: Date of Acceptance by Indiana Secretary of State:______________________________________________ If an Indiana corporation or a foreign corporation, give name and address of Resident Agent:________________________________ Identification of Partners or Corporate Officers Name (last name first) Social Security Number Address City State Zip Code Title Reason License Needed (Answer Yes or No): New Business: Purchase of Existing Business: Lease of Existing Business: From Whom Was Business Purchased or Leased? Reinstatement of Old License: Does Applicant Presently Hold a Cigarette Tax License? ________________ License Number:___________________________ Has Applicant Previously Held a Cigarette Tax License? ________________ License Number:___________________________ Does Applicant Presently Hold an Indiana Registered Retail Merchants Certificate? _________ Certificate Number:_______________________________ Does Applicant Presently Hold Any Other Licenses or Permits Issued by any State Agency? STATE AGENCY TYPE OF LICENSE OR PERMIT NUMBER American LegalNet, Inc. www.FormsWorkflow.com Audit Information: Location Where Records Will Be Available For Audit: Phone Number of Location Of Audit Records: Phone Number of Business Location: Indicate Address of Each Location In Which You Have Other Tobacco Products in Storage Location OTP License Number Indicate Name, Address, Phone Number and Estimated Annual Purchases from Whom You Currently Purchase and/or Expect to Purchase Other Tobacco Products: (A Computer Generated List Which Includes All Requested Information Will Be Accepted) Supplier’s Name Address Phone Number Estimated Annual Purchases TOTAL: If Necessary Attach Additional List. Does Your Company Expect to Sell Other Tobacco Products Into Another State?___________________________________________________________________ List States: _________________________________________________________________________________________________________________________ Today’s Date I declare under penalties of perjury that the information contained in this application and any attachments is true, correct and complete to the best of my knowledge and belief. Signature of Taxpayer or Authorized Agent, Title Telephone Number American LegalNet, Inc. www.FormsWorkflow.com