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2. Tobacco License Application Form - Renewal
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. Select Current License Type*

    Primary Tobacco Dealer - More than 50% of gross revenue is from Tobacco Products, Alternative Nicotine Products, Electronic Smoking Devices, Smoking Herbs, Smoking Accessories and/or Paraphernalia and/or 50% or more of merchandise display area is used for any of the above listed products.

    General Tobacco Sales - Less than or equal to 50% of gross revenue is from Tobacco Products, Alternative Nicotine Products, Electronic Smoking Devices, Smoking Herbs, Smoking Accessories and/or Paraphernalia and less than 50% of merchandise display area is used for any of the above listed products.

    1. Primary Tobacco Dealer
    2. General Tobacco Sales
24. Affidavit of Gross Revenue*

    Upload an affidavit stating the percentage of gross sales from the previous twelve months that were derived from the sale of tobacco products, alternative nicotine products, electronic smoking devices, smoking herbs, smoking accessories and/or paraphernalia.

26. 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%
28. 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%
30. License Type = Primary Tobacco Dealer

    The number of Primary Tobacco Dealer licenses is limited by ordinance.  The current limit of licenses has been reached.  If you are not currently a Primary Tobacco Dealer, this application cannot be approved without an increase to the number of available licenses by the Village Board.

    1. I am a current Primary Tobacco Dealer
    2. I am not currently a Primary Tobacco Dealer and I wish to have my application reviewed to change license type
32. Review Change to License Type
    Contact the Clerk's Office

    Please contact the Village Clerk for review of this change.  Do not pay for renewal after submitting this form as this will delay the licensing process.

34. 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
36. Products for Sale

    Select all that apply

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

    1. I agree

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

43. No False statements

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

45. Full Name*

    Information for individual completing this form.

46. Title*
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

* indicates a required field