Free 52632.xls - Indiana

APPLICATION FOR CIGARETTE IMPORTER OR MANUFACTURER'S LICENSE
State Form 52632 (4-06)

INDIANA ALCOHOL & TOBACCO COMMISSION 302 W. Washington Street, Rm. E114 Indianapolis, Indiana 46204 Tobacco Enforcement: (317) 234-4315 Web page: http://www.IN.gov/atc

STEP 1. GENERAL INFORMATION
Name of Business Entity Business telephone number E-mail address

(
Address of principal place of business City

)

County State Zip

Mailing Address (if different than business) Name of Contact Person Check one: Renewal

City

County License number (if renewal)

State

Zip

License Expiration (if renewal)

Original application

STEP 2. BACKGROUND Yes Yes Yes Yes Yes Yes Yes Yes Yes No Do you, the applicant, owe at least five hundred dollars ($500) in taxes imposed under Indiana Code 6-7-1-12? No Have you the applicant had your tobacco importer or manufacturer's license revoked within the last two (2) years? No Have you, the applicant, violated Indiana Code 24-3-4? No Have you, the applicant, committed any offense under Indiana Code 6-7-1-21 and been found guilty or plead guilty? No Are you, the applicant, in compliance with Indiana Code 24-3-3-12? No Do you understand that cigarettes have to be sold in a pack or carton and that selling single cigarettes is illegal? No Do you understand that this license is not transferable? No Do you understand that the term of this license is one (1) year? No Have you attached the complete list of cigarette distributors licensed in Indiana that you provide cigarettes to? Indiana Code Reference
Any Indiana codes referenced above can be found at http://www.in.gov/legislative/ic/code/ . It is recommended that the applicant review these codes to ensure compliance with Indiana law.

STEP 3. FEE AND PAYMENT SCHEDULE
There is no fee for this One Year License. You may apply in person or by mail. You must provide a complete listing of all distributors in which you provide cigarettes that do business in Indiana.
More information may be found online at http://www.IN.gov/atc.

STEP 4. SIGNATURE AND AFFIRMATION
I certify that this application was completed by myself. 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 portion of this application.
Signature of applicant Date signed (month, day, year)