ILLAGE PRESIDENT
P. Sean Michels
VILLAGE ADMINISTRATOR
Brent M. Eichelberger
VILLAGE CLERK
Cynthia Galbreath
ILLAGE
RUSTEES
Robert Bohler
Kevin Geary
Sean Herron
Mari Johnson
Rick Montalto
David Paluch
APPLICATION FOR A RETAIL TOBACCO RETAILER’S LICENSE
I, We hereby make application for a retail permit to sell tobacco:
BUSINESS INFORMATION
Name of Business/DBA:
Location Address:
Mailing Address:
Telephone Number:____________________
Fax Number: ___________________ Email __________________________________
Types of Sales: Vending Machines Over the Counter
Type of Retail Establishment:
Hotel/Motel
Grocery Convenience with gas Other
Liquor Store
Gas Station Convenience – No Gas Tobacco Store
Restaurant
Bar Department Store
LEGAL OWNER INFORMATION (Type of Ownership):
Individual Partnership Corporation LLC LLP
Legal Owner:
(Name of Individual, Partnership, Corporation, LLC or LLP)
Mailing Address
Telephone Number: ____________________
Fax Number: ______________________
If application is approved and permit granted, I/we do hereby bind ourselves to a faithful observance of the law governing the sale of
tobacco.
Signature of Owner, Partner(s) or Corporate Official
Name (please print):________________________ Name (please print):__________________________
Signature: ________________________________ Signature: __________________________________
Date: ____________________________________ Date: ______________________________________
FOR OFFICE USE ONLY
Date Paid: _____________
Date Issued : ___________
Permit #: ______________
New Renewal
