Application For Other Tobacco Products E Liquid Distributors License {OTP-1A}

State Form 55535 (R / 5-15) OTP-1A Form Application For Other Tobacco Products/E-Liquid Distributor's License Indiana Department of Revenue OTP Renewal OTP New License E-Liquid Renewal E-Liquid New License Federal ID Number Owner's Social Security Number State State State ZIP Code ZIP Code ZIP Code Applicant's Name - Enter Individual, Partnership, or Corporation Name Business/Trade Name (if different from above) Mailing Address (street or P.O. Box number) Physical Address of Business Address Where Audit Records Will Be Available (if different from above) OTP/ E-Liquid License Number (renewals only) Point of Contact Name City City City Telephone Number County County County OTP/ E-Liquid License Expiration Date (renewals only) Telephone Number IndianaTaxIdentificationNumber Email Address Type of Ownership: Provide Name and Address of Resident Agent If Corporation, Provide Date of Incorporation Sole Proprietorship Partnership Corporation LLC If Foreign Corporation, Provide Date of Acceptance by Indiana Secretary of State IdentificationofPartnersorCorporateOfficers Name (Last Name First) Social Security Number Address City State ZIP Code Title Does Applicant Presently Hold Any Other License or Permits Issued by Any State Agency? (Please List Below) State Agency Type of License or Permit Number Yes No Indicate Name and Address from Whom You Currently Purchase and/or Expect to Purchase Other Tobacco Products (A ComputerGenerated List Will Be Accepted). Not applicable to E-Liquid applicants. Supplier's Name Address American LegalNet, Inc. www.FormsWorkFlow.com I declare under penalties of perjury that the information contained in this application is true, correct, and complete to the best of my knowledge and belief. Signature of Applicant or Authorized Agent: __________________________________________________________ Title: _____________________________________________ Telephone Number: _________________________________ Date: _______________________________ You may not do business without your license. This form and $25 payment must be submitted 30 days prior to: A) the expiration of your current license or, B) the date you begin your business. Mail to: Indiana Department of Revenue P.O. Box 901 Indianapolis, IN 46206-0901 American LegalNet, Inc. www.FormsWorkFlow.com