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License Application (New Jersey)

This is an application for a license to manufacture, distribute, etc. cigarettes or motor fuel oil in New Jersey. The form provided here is simply a sample of what the actual Form CM-100 looks like.

CM-100

State of New Jersey
DIVISION OF TAXATION

Mail to:

Client Registration
PO Box 252
Trenton, NJ 08646-0252


LICENSE APPLICATION

OFFICIAL USE ONLY

DLN

PLATE NO.

CHECK ONE BOX COMPLETE INFORMATION BELOW, ENCLOSE FEE

____ Motor Fuel Retail Dealers License (three (3) year license) (complete A & B below) . . . . . . . . . . . . . . . . . . . $ 150.00

____ Motor Fuel Transport License (complete A & C below) . . . . . . . . . . . . . . . . . . . . $ 50.00

____ Cigarette Manufacturer Representative License (one (1) year license) (complete A & D below) . . . . . . . . . . $ 5.00

____ Cigarette Vending Machine License (one (1) year license) (complete A & F below) . . . . . . . . . . . . . . . . . . . $ 50.00

____ Cigarette Retail Dealers Over-the-Counter License (one (1) year license) (complete A & E below) . . . . . . . $ 50.00

(A separate application must be filed for each license type)

A. All applicants must complete Part A

Federal Identification Number ___ ___ - ___ ___ ___ ___ ___ ___ ___

____ Check box if this is a license renewal

Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Name ____________________________________ (Corporate, partners, proprietor, representative)

Trade Name ____________________________________

Business Location Address ____________________________________

Street ____________________________________

City ____________________________________

State ____________________________________

Zip Code ____________________________________

Mail Name and Address ____________________________________

Street ____________________________________

City ____________________________________

State ____________________________________

Zip ____________________________________

Code ____________________________________

TYPE OF OWNERSHIP

____ Corporation
____ Proprietorship
____ Partnership
____ Representative
____ Other ___________________________

Date business began in New Jersey _______ / _______ / _______ (Mo/Day/Yr)

Contact Telephone Number (_____) _______ - ____________

OWNER INFORMATION

Name ____________________________________

Title ____________________________________

Social Security No. ____________________________________

Home Address ____________________________________

Complete the information below which pertains to the specific license.

B. Motor Fuel Retail Dealers License

Number of pumps . . . . . . . . .__________________________

Capacity in gallons . . . .______________________________

Name of supplier . . . . . . . . . .__________________________

Do you sell diesel? . . . . . . . . .__________________________

Brand sold . . . . . . . . . .______________________________

C. Motor Fuel Transport License

State License Plate Number . .__________________________

Make of vehicle . . . . . . .______________________________

Vehicle identification number .__________________________

Barge name . . . . . . . . . . . . . .__________________________

Year . . . . . . . . . . . . . . .______________________________

D. Cigarette Manufacturer Representative License

Name of company you represent ____________________________________

E. Cigarette Retail Over-The-Counter License

Name of company where you purchase your cigarettes ____________________________________

F. Cigarette Vending Machine License

Number of machines you are applying for _________________________ (Enclose a $50.00 fee for each machine)

Name of company where you purchase your cigarettes ____________________________________

You must attach a list with the physical address of each vending machine

Signature ____________________________________

Date ____________________________________

All appropriate information must be completed and the application must have an authorized signature to be processed.

FEE MUST ACCOMPANY APPLICATION

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