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New York State Department of Taxation and Finance
Application for a License as a
Wholesale Dealer of Tobacco
Products or an Appointment
as a Distributor of Tobacco Products
Tax Law — Article 20
Read Form MT-202-I, Instructions for Form MT-202, carefully before completing this application. For
additional requirements, see Form MT-202-C, Checklist for Form MT-202. Attach additional sheets if
necessary to fully answer all questions. No fee required. Subject to renewal every 3 years.
Mark an X in the appropriate box(es) for which you are applying (see instructions for definitions).
Distributor of tobacco products Wholesale dealer of tobacco products
Print or type
Name
Social security number (SSN)
Percentage of ownership Home/cell phone number
( )
Home address (number and street) City State ZIP code Title
Name SSN Percentage of ownership Home/cell phone number
( )
Home address (number and street) City State ZIP code Title
Name SSN Percentage of ownership Home/cell phone number
( )
Home address (number and street) City State ZIP code Title
Name SSN Percentage of ownership Home/cell phone number
( )
Home address (number and street) City State ZIP code Title
Name SSN Percentage of ownership Home/cell phone number
( )
Home address (number and street) City State ZIP code Title
10b All other owners each hold 10% or less (less than 25% if 4 or fewer shareholders) of the voting stock in the company together totaling ...... %
For office use only
1 Legal name Telephone number
( )
2 Trade name (if different from line 1)
3 Address of principal place of business (number and street) City State ZIP code 4 County
5 Type of business organization:
Individual Partnership Corporation Other (specify):
6 Tobacco products related activities (mark an X in all the boxes that apply)
Manufacturer (roll cigars) Importer Distributor located in New York State
Wholesaler Exporter Out-of-state distributor
Retailer Tobacco products vending machine operator Other
7 Mailing address (if different from line 3) City State ZIP code
8
a. Federal employer identication number (EIN
)
b. Other federal EIN, if any 9 Date you began or expect to begin business in New York State
10a List owners, ofcers, directors, partners, shareholders, or sole proprietor and all responsible persons (see instructions; attach additional sheets if necessary).
MT-202
(6/08)
