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