Vermont Vermont Wholesale Cigarette and Tobacco Dealer License Application

Vermont Wholesale Cigarette and Tobacco Dealer License Application
Form CTT-647
Vermont Department of Taxes
Phone: (802) 828-2551

VT Form

CTT-647

133 State Street

Montpelier, VT 05633-1401

VERMONT WHOLESALE CIGARETTE
AND TOBACCO DEALER
LICENSE APPLICATION

TYPE or PRINT - Incomplete and/or illegible applications will be returned.

Business Information
Business/Entity Type (check ONE)
	  Sole Proprietor (Individual, Married, or Civil Union)	
	  Single Member LLC	

 Partnership	
 LLC	

 S-Corporation	
 Other

Owner (Name of Corporation, LLC, or Partnership)				

 C-Corporation

FEIN

OR
Individual Last Name (Sole Proprietor only)	

First Name		

MI	

Social Security Number

Spouse/CU Partner Last Name (Sole Proprietor only)	

First Name		

MI	

Spouse/CU Partner Social Security Number

Trade Name or d/b/a				

Primary Contact Name (Last, First, Middle)

Business Mailing Address				

Telephone Number

City		

Fax Number

State	

ZIP Code		

E-mail Address				

Business Activity (check all that apply)

 Manufacturer
 Retailer
 Dealer

Business Physical Address	
City		

State	

ZIP Code

Principal Owners - List if the applicant is a corporation, partnership, or LLC (ownership of 10% or more).
PRINCIPAL OWNER #1
Last Name	

First Name			

Address		

MI

City			

State	

PRINCIPAL OWNER #2
Last Name	

First Name			

Address		

MI

City			

First Name			

Address		

City			

(continued on next page)

MI

ZIP Code

For Department Use Only
State	

PRINCIPAL OWNER #3
Last Name	

For Department Use Only

ZIP Code

For Department Use Only
State	

ZIP Code

Form CTT-647
Page 1 of 2
Rev. 06/19

Entity name
FEIN

Questions
	1.	 Has your business previously applied for a Vermont Wholesale Cigarette and Tobacco
Dealer License?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Yes	

 No

	 2.	 Do you have multiple locations with Cigarette and Tobacco inventory?. . . . . . . . . . . . . . . . . . . .   Yes	

 No

	 3.	 Do you sell unstamped cigarettes or small cigars to businesses or customers outside of
Vermont?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Yes	

 No

		3a.	 If you answered “Yes” to Question #3, which state(s): ______________________________________________
	 4.	 List addresses of all warehouses or storage facilities where Vermont stamped cigarettes handled by you are stored.
Address		

City			

State	

ZIP Code

Address		

City			

State	

ZIP Code

Address		

City			

State	

ZIP Code

Address		

City			

State	

ZIP Code

	 5.	 Will you be sending samples of unstamped cigarettes or small cigars to licensed
Vermont Dealers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Yes	

 No

	6.	 Will you be affixing tax stamps to packages of cigarettes purchased for sale to retailers?. . . . . .   Yes	

 No

	 7.	 Will you be purchasing for sale any of the following products from out-of-state unlicensed suppliers:
		7a.	 Cigars, cigarillos, chewing tobacco, pipe tobacco, blunts and wraps, new smokeless
tobacco, snus, orbs, “dry” snuff in pouches, or smokeless hard tobacco? . . . . . . . . . . . . . . .   Yes	

 No

		7b.	 Snuff?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Yes	

 No

		7c.	 Roll-your-own tobacco?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Yes	

 No

		7d.	 Little cigars?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Yes	

 No

		7e.	 Electronic cigarettes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Yes	

 No

		7f.	 Other? ______________________________________________________ . . . . . . . . . . . .   Yes	

 No

If the products you are selling change, it is your responsibility to notify the Vermont Department of Taxes in writing.

Signature
I hereby certify that I have examined this return, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature			Date	
Printed Name	

Title	

Telephone Number

Form CTT-647
Page 2 of 2
Rev. 06/19