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2. Tobacco License Application Form - New
4. Business Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Phone Number *
13. Email Address*

    Renewal notices will be sent here

15. Contact Person
17. Contact Phone Number
18. Contact Email Address
22. Expected Percentage of Gross Revenue from Tobacco Products, Alternative Nicotine Products, Electronic Smoking Devices, Smoking Herbs, Smoking Accessories and/or Paraphernalia*

    1. Less than or equal to 50%
    2. More than 50%
24. Expected Percentage of Merchandise Display area devoted to Tobacco Products, Alternative Nicotine Products, Electronic Smoking Devices, Smoking Herbs, Smoking Accessories and/or Paraphernalia

    1. Less than 50%
    2. Equal to or more than 50%
26. License Type = Primary Tobacco Dealer

    The number of primary tobacco dealer licenses is limited by ordinance.  The current limit of licenses has been reached.  This application cannot be approved without an increase to the number of available licenses by the Village Board.

    1. I understand the above statement and I wish to have my application reviewed.
28. License Type = General Tobacco Sales

    Application for license renewal must be accompanied by an affidavit stating the actual percentage of gross sales from tobacco products, alternative nicotine products, electronic smoking devices, smoking herbs, smoking accessories and/or paraphernalia during the twelve months prior to renewal.

    
    

    1. I understand the above statement and will keep records to provide this information.
    2. I affirm that expected revenue and merchandise display areas are accurate to the best of my knowledge
30. Upload Floor Plan

    Floor plan shall indicate merchandise layout with dimensions sufficient to determine the percentage of area devoted to the display of all products.

32. Products for Sale

    Select all that apply

    1. Tobacco Products
    2. Alternative Nicotine Products
    3. Electronic Smoking Devices
    4. Accessories and/or Paraphernalia
34. Required Sign for Sales to Customers Under 21 Years of Age
    Download a copy here
38. Execute*

    1. I agree

    By selecting I agree option below you are giving your electronic signature.

39. No False statements

    Your submission of this form certifies that the information provided is true and correct.

41. Full Name*

    Information for individual completing this form.

42. Title*
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

* indicates a required field