Application For Cigarette Distributors Registration Certificate {CIG-1A}

State Form 48477 (R3 / 2-14) CIG-1A Form Application For Cigarette Distributor's Registration Certificate Indiana Department of Revenue Renewal New Certificate 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) CIG License Number (renewals only) Point of Contact Name City City City Telephone Number County County County Federal ID Number Owner's Social Security Number State State State ZIP Code ZIP Code ZIP Code CIG License Expiration Date (renewals only) Telephone Number Indiana Tax Identification Number 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 Identification of Partners or Corporate Officers Name (Last Name First) Social Security Number Address City State ZIP Code Title Are you Registering to be a Stamping Distributor? Yes No Type of License or Permit Does Applicant Presently Hold Any Other License or Permits Issued by Any State Agency? (Please List Below) State Agency Number Yes No From What Source Do You Intend to Buy Cigarettes? Direct from Manufacturer Wholesaler Outside the State of Indiana Indiana Distributor Does Your Company Expect to Sell Cigarettes into Another State? Yes No Unstamped Unstamped Stamped Stamped 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 Taxpayer or Authorized Agent: __________________________________________________________ Title: _____________________________________________ Telephone Number: _________________________________ Date: _______________________________ You may not do business without your certificate. This form and $500 payment must be submitted 30 days prior to: A) the expiration of your current certificate 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