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TOBACCO TRADE GROUP CORP
U.S. FDA / FEI - 3042737563
U.S. FDA / CTP - ID RG8912
U.S. TTB - Importer FL-TI-40275

New client account form

Legal Business Name

DBA

Entity Type

Business Type

EIN / Federal Tax ID

Website

Primary Contact

Title

Phone

Resale Certificate No.

State

Tobacco License Type

Issuing State

License Number

Expiration Date

MM/DD/YYYY.

Additional License Type

Select an option

Additional Issuing State

Billing? Resale Shipping

Additional License Number

Additional Expiration Date

MM/DD/YYYY.

Preferred Language

Billing Address

Billing City

Billing State

Billing ZIP Code

Shipping Same as Billing?

Yes — Use billing address
No — Different shipping address

If yes, you may leave the shipping address fields blank.

Shipping Contact

Shipping Address

Shipping City

Shipping State

Shipping ZIP Code

Authorized Name

Authorized Title

Date

MM/DD/YYYY

Certification & Acceptance

I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge. I confirm that I am authorized to submit this application on behalf of the business identified above. I understand that submitting this application does not guarantee approval of a wholesale account with Tobacco Trade Group Corp.

TOBACCO TRADE GROUP CORP
U.S. FDA / FEI - 3042737563
U.S. FDA / CTP - ID RG8912
U.S. TTB - Importer FL-TI-40275

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New client account form

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