Reset Form P.O. Box 530 Columbus, OH 43216-0530 CIG 40 Rev. 3/14 Application for Retail Cigarette Dealer's License (Please mail two copies to the office of the county auditor.) For the period from To the auditor of Taxing district 20 County Date Fee to 20 Pursuant to R.C. 5743.15, the applicant herein has paid the required fee to the county treasurer for each place of business specified below and hereby requests a license to sell cigarettes at retail at each of those places of business. 1. Name of dealer (If sole owner, print individual's full name; if partnership, print full names of all partners; if corporation, print corporation's name and Ohio corporation charter number. If a foreign corporation, give certificate number issued by secretary of state authorizing transaction of business in Ohio. R.C. 1703.01 et seq.) 2. Check whether dealer operates as: Sole owner Partnership Corporation Fiduciary Association LLC LLP Other 3. List below the titles, names and address of all corporate officers, association officers or partners Title Title Name Name Street Street City City State State ZIP ZIP 4. Trade name (if other than above) 5. Sales tax vendor license number (required) 6. Federal employer identification number or, if none assigned for reporting federal taxes, please enter your Social Security number FEIN Social Security number 7. Place of business (the license fee must be paid for each business location listed) Street Street City City State State ZIP ZIP License no. (Filled in by county) License fee (Filled in by county) License no. (Filled in by county) License fee (Filled in by county) (Additional places to be listed on separate sheet and attached hereto.) 8. E-mail address 9. Residence address of dealer or home office of corporation Street City State ZIP I declare under penalties of perjury that the above statements have been examined by me and to the best of my knowledge and belief is a true, correct and complete report. Signature of dealer or officer of company Telephone number All questions on this application should be fully answered before the licenses requested hereon are issued. For further license information, see reverse side of this form. American LegalNet, Inc. www.FormsWorkFlow.com License Information A cigarette dealer's license does not authorize the licensee to engage in the business of trafficking in cigarettes at any place of business in this state other than that specified thereon by the county auditor. There is no discount for multiple locations. In the event that a business is moved from one location to another within the same county, the holder of the retail license may transfer the license for a fee of $5. In the event that a business is sold, or an individual or partnership incorporates his or their business, or a partnership or corporation is dissolved, the cigarette license that has been issued to a dealer prior to the occurrence of any such event may not be used, and a new license must be obtained. Important Notice: Ohio recently passed legislation that prohibits the sale of cigarettes in Ohio that have not been approved by the attorney general's office. A list of brands legal for sale in Ohio can be found at www.attorneygeneral.gov/Services/ Business/Tobacco-Directory-Search. This list is periodically updated. Any brand not listed on this Web site is considered contraband and is subject to confiscation. American LegalNet, Inc. www.FormsWorkFlow.com