HomeMy WebLinkAboutTobacco Iowa Retail Permit Application
N ( A1fin ~f A rx Department of Revenue
for Ckiarette/TobaccofNiicotineNapor
tax.iowa.gov
Additional instructions are on the final page.
For period (MM/DDIYYYY) , 1 / through 06/301
Use this form to apply for a retail permit to sell cigarettes, tobacco, alternative nicotine, or vapor products
at retail. If you need a different, non-retail cigarette or tobacco permit, use form 70-01 5. If approved, the
permit is only valid for the location listed on the permit. You must obtain a separate retail permit for each
location you own or operate.
Business Information:
Legal name/Doing business as (DBA);
Iowa sales and use tax account number:
Retail address: City: State: ZIP:
Mailing address: City: State: ZIP:
Phone:
Legal Ownership Information:
Type of ownership: Sole Proprietor 0 Partnership 0 Corporation 0 LLC 0 LLP 0
Name of sole proprietor, partnership, corporation, LLC, or LLP:
Primary office address: City: State: ZIP:
Phone: Fax: Email:
Retail Information:
Types of Sales: Over-the-counter ❑ Vending machine 0 Vending machine that assembles
cigarettes 0 Delivery sales of alternative nicotine/vapor products (see instructions) 0
Mobile sales (see instructions) 0 VIN: License plate number:
Types of Products Sold: (Check all that apply)
Cigarettes 0 Tobacco 0 Alternative nicotine products ❑ Vapor products ❑
Type of Establishment: (Select the options that best describe the establishment)
Alternative nicotinelvapor store 0 Bar 0 Convenience store/gas station ❑ Drug store 0
Grocery store ❑ Hotel/motel 0 Liquor store 0 Restaurant 0 Tobacco store 0
Other (provide description) 0
Do you have other permits issued under Iowa Code chapter 453A at this retail location? If yes, provide
permit numbers):
Do you intend to make retail sales to ultimate consumers? Yes 0 No ❑
Include with this application a list of your suppliers of cigarettes, tobacco, alternative nicotine and vapor
products on a separate sheet.
Identify partners or corporate officers (up to three) if the business is not a sole proprietorship,
Name: Title:
Address:
City: _ State, ZIP:
Name: Title:
70-014a (05/01/2024)
Iowa Retail Permit Application for Cigarette/Tobacco/NicotineNapor,page 2
Address:
City: State: ZIP:
Name: Title:
Address:
City: State: ZIP:
If this application is approved and a permit Is granted, I/we do hereby bind ourselves to a faithful
observance of the laws governing the sale of cigarettes,tobacco,alternative nicotine,and vapor products.
Signature of Authorized Party
I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this
application,and to the best of my knowledge and belief, it is true,correct,and complete. I declare that I
am authorized to act on behalf of the taxpayer,and will only act within my authority.
Printed Name/Title:
Authorized Signature:
Date: Email:
Send this completed application and the applicable fee to your local jurisdiction. If your local jurisdiction
permits electronic transmission of this application, your email or fax signature will constitute a valid
signature.It Is up to your local jurisdiction to approve this application and Issue the permit.You must have
an approved permit issued to you by the local jurisdiction before acting as a retailer in that jurisdiction.You
must separately apply In each local jurisdiction in which you plan to act as a retailer. If you have any
questions about the status of your application, contact your city clerk(within city limits)or your county
auditor(outside city limits).NOTE:A completed application is NOT a valid permit even if submitted to your
local jurisdiction with the applicable fee.
FOR CITY CLERK/COUNTY AUDITOR ONLY—MUST BE COMPLETE
•Fill in the amount paid for the permit: Send completed/approved application to the Iowa
• Fill in the date the permit was approved Department of Revenue within 30 days of
by the council or board: issuance. Make sure the information on the
application is complete and accurate. A copy of the
• Fill in the permit number issued by permit does not need to be sent;only the application
the city/county: is required. If a permit is being exchanged due to
• Fill in the name of the city or county change of location within the same jurisdiction,
Issuing the permit: permittee should complete an application with new
•New 0 Renewal ❑ location Information and application should be sent to
the Department as described above.Permittees who
exchange a valid permit are not required to pay an
additional fee when an exchange application is
submitted.It is preferred that applications are sent via
email,as this allows for a receipt confirmation to be
sent to the local authority.
• Email:iapiedge@iowaabd.com
• Fax:515-281-7375
70.014b(05/01/2024)