CT102
(Rev. 4/17)
Type of legal organization (check one):
Sole proprietor Minnesota corporation: Enter date of incorporation
Partnership Out-of-state corporation: State of incorporation
Other (describe) Are you registered to do business in Minnesota? Yes No
Corporate ofcers or partners (attach a list if necessary)
Name Title
Address City State ZIP Code
Name Title
Address City State ZIP Code
Business Information
As a licensed tobacco products or cigarette retailer, I understand that:
1. I can purchase cigarettes only from a Minnesota distributor or subjobber who holds a license with the Minnesota Department of
Revenue.
2.
I must obtain a tobacco products distributor license if I purchase untaxed tobacco products from an out-of-state company.
3. ImaynotsellcigarettesafxedwithMinnesotaNativeAmericanstampsunlessmyretailbusinessislocatedonareservationthat
has a tax agreement with the State of Minnesota.
4. I may not purchase from or exchange cigarettes or tobacco products with another retailer.
5. I must keep complete and legible cigarette and tobacco products invoices on the licensed premises, or make invoices available
within one hour of request, for at least one year after the date of the purchase.
6. I know that the Minnesota Department of Revenue and/or law enforcement may conduct cigarette and tobacco inspections of
the premises, including inspections of inventory, invoices and licenses, and I understand that a refusal to allow an inspection is
grounds for revocation of my license.
7. I know that failure to comply with all requirements can result in criminal penalties, including the loss of cigarettes and tobacco
products.
Statement of Understanding
License Application to Make Retail Sales of Cigarette and Other Tobacco Products
To be completed by applicant when applying for a license with a city or county.
Applicant’s Minnesota Tax ID Number
License Authority
License Number
Period Covered
Date of Issuance
FOR MUNICIPAL USE ONLY
The Minnesota Tax ID must be issued in the same
legal name of the licensee below.
Cigarettes/tobacco products will be sold (a separate license is required
for each location or vending machine):
Over Counter Through Vending Machine Both
Print or Type
Licensee’s Legal Name Federal Employer ID Number (FEIN)
Business Trade Name (doing business as) Daytime Phone
Complete Address of Business Location (permit location) County Other Phone Number
City State ZIP Code Fax Number
Mailing Address (if different than business address) City State ZIP Code Email Address
Licensee Signature Title Print Name Date Daytime Phone
Licensing Agent’s Signature Title Print Name Date Daytime Phone
License applicant: Submit this form to the licensing authority along with the license application.
Licensing authority: Mail, email or fax to:
Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331.
Fax: 651-556-5236. Email: cigarette.tobacco@state.mn.us
Sign Here
