Local Tobacco Permit Application Compliance Check: Local Permit Application Store Name* Tobacco Specialty Shop General Tobacco Retailer Map of Proposed Location for Retail Tobacco Specialty Business (Required for all retail tobacco specialty businesses, must show on the map the location of the business and distances from the noted locations above.) Street Address 1* Street Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Phone Number Store E-mail Address Cigarette/Tobacco Products License* Date of Application Mailing Address Street Address 1* Street Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Proprietor 1 Details Name* Address 1* Address 2 City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code* Phone Number* E-mail Address* Authorized to receive tobacco permit and permit-related communications and notices* Proprietor 2 Details Name Address 1 Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Phone Number E-mail Address Have any of the proprietors applying for a tobacco license listed above been determined to have violated any state or federal tobacco laws in the past 24 months? If so, list all violations and dates of each violation: I certify that the information provided is true and accurate to the best of my understanding. I understand that any incorrect information may result in the suspension or revocation of the health department’s tobacco permit. I also understand that the health department may recommend to the business licensing entity that the business license be suspended or revoked. Any such action will be reported to the Utah State Tax Commission. If the information required in this application changes a tobacco retailer may not renew their permit and must apply for a new permit no later than 15 days after the information changed. By clicking submit I am signing this application and my signature binds all proprietors for the business listed on this application to the above agreements. I agree to the Terms* Powered by QuickBase Online Database