application for license to sell tobacco ......application for license to sell tobacco products north...

APPLICATION FOR LICENSE TO SELL TOBACCO PRODUCTS NORTH DAKOTA OFFICE OF ATTORNEY GENERAL LICENSING SECTION SFN 61612 (02-2021)

License Number

License Year

Please print or type legibly or it will delay processing. ALL APPLICANTS MUST COMPLETE Application is for

New license License renewalLicense is for

Retail location Wholesale/Distributor

Applicant Name (if corp., LLC, etc., enter legal name)

Business Name

Mailing Address City State ZIP Code County

Business Address City State ZIP Code County

Business Telephone Number Other Contact Telephone Number

Person to Contact Regarding Application QuestionsName Telephone Number E-mail Address

NEW APPLICANTS ONLYDescription of business Intended beginning date to sell tobacco products

Are you taking over this business from someone?Yes No

If yes, enter the previous owner's name

ALL APPLICANTS MUST COMPLETEName of Individual Authorized to Sign on Behalf of Applicant (Print Name) Official Position

Signature of Authorized Individual Date

Tobacco licenses expire on June 30th of each year and must be renewed before expiration or a reinstatement fee will be required.

LICENSE FEE: Retail $15.00 Wholesale/Distributor $25.00 PAYABLE TO: Attorney General

For Licensing Use Only

Mail to: Office of Attorney General Licensing Section 600 E Boulevard Ave Dept. 125 Bismarck ND 58505-0040

Questions please call (701) 328-2329

Wholesale/Distributor Federal EIN

Cigars Cigarettes Chewing Tobacco SnuffPipe Tobacco Other (Please Explain)

Wholesale/Distributor types of tobacco products to be sold or imported