Application For Tobacco Sales Certificate {51357}

APPLICATION FOR TOBACCO SALES CERTIFICATE State Form 51357 (R3 / 5-15) Approved by State Board of Accounts, 2015 INDIANA ALCOHOL AND TOBACCO COMMISSION TOBACCO ENFORCEMENT 302 W. Washington Street, Room E114 Indianapolis, IN 46204 Telephone: (317) 234-4315 Website: http://www.IN.gov/atc STEP 1. GENERAL INFORMATION Name of business entity Telephone number of business E-mail address Address where tobacco products are sold (number, street, room number, city, state and ZIP code Mailing address (if different) (number and street, city, state, and ZIP code) Doing business as (DBA) Check one: Certificate number (if renewal) Certificate expiration date (if renewal) Renewal Original application STEP 2. BACKGROUND For the purposes of this section, tobacco shall have the meaning set forth in Ind. Code 35-46-1-1.7 and electronic cigarette or e-cigarette shall have the meaning set forth in Ind. Code 35-46-1-1.5. Note this includes any device capable of delivering inhalable nicotine by a vaporized solution, including components and cartridges. Components include e-liquids. Do you understand that it is against Indiana law to sell tobacco or e-cigarettes (meaning a device capable of providing an Yes No inhalable dose of nicotine by a vaporized solution, including components, cartridges and e-liquids) to someone less than eighteen (18) years of age? Do you understand that under Indiana law access to tobacco and e-cigarette vending machines is illegal to people less Yes No than eighteen (18) years of age? Do you understand that under Indiana law access to tobacco and e-cigarettes including components, cartridges and eYes No liquids is illegal to people less than eighteen (18) years of age? Do you understand that under Indiana law you must post the proper tobacco signage depending on what type of tobacco Yes No vendor you are? Do you understand that the identification of anyone that appears under the age of twenty-six (26) should be checked Yes No before selling them a tobacco or e-cigarette product including e-liquid? Do you understand that valid forms of identification include only the following government issued photo IDs: a Driver Yes No License, a State issued ID card, a US Passport, a US Military ID card, and a US Immigration card? Yes No Do you understand that cigarettes have to be sold in a pack or carton and that selling single cigarettes is illegal? Yes 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? Do you understand that if you sell tobacco or e-cigarette products including e-liquids without a valid certificate, you may be Yes No fined up to $1000.00? Yes No Do you understand that your tobacco certificate must be renewed every three (3) years? Do you understand that a new business selling tobacco may not operate within two hundred (200) feet of a public or Yes No private elementary or secondary school? Yes No Is your business located within two hundred (200) feet of a public or private elementary or secondary school? Yes No Do you understand that the Indiana cigarette fair trade law must be followed at all times? Do you understand that tobacco sales certificate must be posted in accordance with 905 IAC 1-46-1 of the Indiana Yes No Administrative Code? Do you consent for the duration of the permit to inspection and search by an enforcement officer, without a warrant or Yes No other process, of your licensed premises and vehicles to determine compliance with the provisions of I.C. 7.1? Yes No Do you sell tobacco? Do you sell e-cigarettes ­ defined as any device capable of delivering inhalable nicotine by a vaporized solution, including Yes No components, cartridges and e-liquids? Do you understand that all tobacco products must come from a licensed distributor/wholesaler and you must be able to Yes No provide an invoice or documentary evidence of this upon inspection of your premises? (IC 24-3-2-4.7) STEP 3. ATTACH COPY OF REGISTERED RETAIL MERCHANT CERTIFICATE Attach or e-mail a copy of your unexpired Registered Retail Merchant Certificate (RRMC) along with this application. E-mails may be sent to NAnderson1@ATC.IN.GOV. Contact 317.232.2165 (Indiana Department of Revenue) for assistance in obtaining or renewing your RRMC. STEP 4. FEE AND PAYMENT SCHEDULE There is a $200.00 fee for a three (3) year certificate. You may apply in person, by mail, or online. Payment by mail may be money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECK. Apply online at http://www.IN.gov/atc and pay with MasterCard or Visa. STEP 5. SIGNATURE AND AFFIRMATION I certify that this application was completed by me. 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 position of this application. Signature of applicant Date signed (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com