CTP-200 (R. 9-15)
Wisconsin Department of Revenue
Application for Cigarette and
Tobacco Products Retail License
License Number
Period Covered
Date of Issuance
MUNICIPAL USE ONLY
Applicant’s Wisconsin 15-digit Sales Tax Account Number
This must be issued in the same
Legal Name of the licensee below.
YES NO 1. Does the applicant understand that they must purchase cigarettes only from distributors or jobbers
who hold a permit with the Wisconsin Department of Revenue?
YES NO 2. Does the applicant understand that they must obtain a Tobacco Products Distributor permit if purchasing
untaxed tobacco products from an out-of-state company? (Tobacco Products Distributor permit is
available from the Wisconsin Department of Revenue at 608-261-6435. See application form CTP-
129, revenue.wi.gov/forms/excise/ctp-129.pdf.)
YES NO 3. Does the applicant understand that they cannot purchase/exchange cigarettes or tobacco products
from another retailer, including transferring existing stock to a new owner?
YES NO 4. Does the applicant understand that they must provide employees with tobacco sales training approved
by the Wisconsin Department of Health Services? (SmokeCheck.org)
YES NO 5. Does the applicant understand that they may not sell, give or otherwise provide cigarettes/tobacco
products and nicotine products to minors (including electronic cigarettes containing nicotine)?
YES NO 6. Does the applicant understand that they may not sell single cigarettes?
YES NO 7. Does the applicant understand that cigarette and tobacco products invoices must be kept on the
licensed premises for two years from the date of the invoice and be available for inspection by the
Wisconsin Department of Revenue/law enforcement and that failure to comply can result in criminal
penalties, including loss of cigarettes/tobacco products?
YES NO 8. Does the applicant understand that only cigarettes and roll-your-own (RYO) tobacco products listed on
the Wisconsin Department of Justice’s website labeled “Directory of Certied Tobacco Manufacturers
and Brands” at www.doj.state.wi.us/dls/tobacco-directory may be sold in Wisconsin?
Business Located In
City Village Town
Legal Name (corporation, limited liability company, partnership or sole proprietorship)
Trade or Business Name (if different than Legal Name)
Business Address (License Location)
City State ZIP Code
Mailing Address (if different than Business Address) City State ZIP Code
Federal Employer Identication No. (FEIN)
Telephone Number
( )
Business Telephone
( )
County
of:
Organization (check one)
Sole Proprietor
Partnership
Wisconsin Corporation – Enter date incorporated:
Out-of-State Corporation – Are you registered to do business in Wisconsin? YES NO
Other (describe)
SUBSCRIBED AND SWORN TO BEFORE ME
this day of , 20
My commission expires
(Clerk / Notary Public)
(Ofcer of Corporation/Member/Manager of Limited Liability Company/Partner/Individual)
READ CAREFULLY BEFORE SIGNING: Under penalty provided by law, the applicant states that each of the above questions has
been truthfully answered to the best of the knowledge of the applicant. Applicant agrees to operate this business according to law and
that the rights and responsibilities conferred by the license(s), if granted, cannot be assigned to another.
Any lack of access to any portion of a licensed premises during inspection will be deemed a refusal to permit inspection. Such refusal
is a misdemeanor and grounds for revocation of this license.
Cigarettes / Tobacco will be sold over counter through vending machine both
Submit to municipal clerk.
FEE: $100
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7/1/2016 -6/30/2017
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