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D Oregon business identification number (BIN) (only for businesses) Program code Mailing address 514 City Year State Period 11 Liability 1 ZIP code Please read the instructions on the back of this form. Example of completed form: Invoice Example: A. Distributor from whom cigarettes were purchased B. Number 8251786-394 Example: ABC Internet Cigarette Company C. Date 1/28/11 D. Number E. Packs F. Cigarettes of cartons per carton per pack 2.

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