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Get Tobacco Sales Certificate Indiana Form 2005-2021

APPLICATION FOR TOBACCO SALES CERTIFICATE INDIANA ALCOHOL TOBACCO COMMISSION 302 W. Washington Street Rm. E114 State Form 51357 R/7-05 Approved by State Board of Accounts 2005 Indianapolis Indiana 46204 Tobacco Enforcement 317 234-4315 Web page http //www. IN*gov/atc STEP 1. GENERAL INFORMATION Name of Business Entity Business telephone number Address where tobacco products are sold number street room City Mailing Address if different than business - DBA Check one o Renewal E-mail address County State Zip Certificate number if renewal Certificate Expiration if renewal o Original application STEP 2. BACKGROUND o Yes o No Do you understand that it is against Indiana law to sell a tobacco product to someone under 18 years of age o No o Yes o No Do you understand that valid forms of identification include the following government issued IDs a Drivers License a State Issued ID card a US Passport a US Military ID card and a US Immigration card. STEP 3. FEE AND PAYMENT SCHEDULE There is a 200 fee for a 3 Year Certificate. You may apply in person by mail or online. Payment by mail may be by money order business check or certified check. DO NOT SEND CASH OR PERSONAL CHECKS* Apply online at http //www. IN*gov/atc and pay with MasterCard or Visa* STEP 4. SIGNATURE AND AFFIRMATION I hereby consent for the duration of the certificate term to inspection and search by an excise enforcement officer without warrant or other process of my certificate premise and vehicles to determine compliance with the provisions of I. IN*gov/atc STEP 1. GENERAL INFORMATION Name of Business Entity Business telephone number Address where tobacco products are sold number street room City Mailing Address if different than business - DBA Check one o Renewal E-mail address County State Zip Certificate number if renewal Certificate Expiration if renewal o Original application STEP 2. BACKGROUND o Yes o No Do you understand that it is against Indiana law to sell a tobacco product to someone under 18 years of age o No o Yes o No Do you understand that valid forms of identification include the following government issued IDs a Drivers License a State Issued ID card a US Passport a US Military ID card and a US Immigration card. BACKGROUND o Yes o No Do you understand that it is against Indiana law to sell a tobacco product to someone under 18 years of age o No o Yes o No Do you understand that valid forms of identification include the following government issued IDs a Drivers License a State Issued ID card a US Passport a US Military ID card and a US Immigration card. STEP 3. FEE AND PAYMENT SCHEDULE There is a 200 fee for a 3 Year Certificate. You may apply in person by mail or online. STEP 3. FEE AND PAYMENT SCHEDULE There is a 200 fee for a 3 Year Certificate. You may apply in person by mail or online. Payment by mail may be by money order business check or certified check. DO NOT SEND CASH OR PERSONAL CHECKS* Apply online at http //www. Payment by mail may be by money order business check or certified check. DO NOT SEND CASH OR PERSONAL CHECKS* Apply online at http //www. IN*gov/atc and pay with MasterCard or Visa* STEP 4. SIGNATURE AND AFFIRMATION I hereby consent for the duration of the certificate term to inspection and search by an excise enforcement officer without warrant or other process of my certificate premise and vehicles to determine compliance with the provisions of I..

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