E-5 - Tobacco Licenses Approval

Additional instructions are on the final page. For period (MM/DD/YYYY) 07 / 01 / 2024 through 06/30/2025 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 70-015. 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): CASEY'S #2667 Iowa sales and use tax account number: 0-00-007787 Retail address: 403 STEPHANS ST City: TIFFIN State: IA ZIP: 52340 Mailing address: ONE SE CONVENIENCE BLVD. City: ANKENY State: IA ZIP: 50021 Phone: (319) 220-8762 Legal Ownership Information: Type of ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☒ LLC ☐ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or LLP: CASEY'S MARKETING COMPANY Primary office address: ONE SE CONVENIENCE BLVD. City: ANKENY State: IA ZIP: 50021 Phone: 515-446-6404 Fax: 515-446-6303 Email: [email protected] Retail Information: Types of Sales: Over-the-counter ☒ Vending machine ☐ Vending machine that assembles cigarettes ☐ Delivery sales of alternative nicotine/vapor products (see instructions) ☐ Mobile sales (see instructions) ☐ VIN: __________________________ License plate number: ________________ Types of Products Sold: (Check all that apply) Cigarettes ☒ Tobacco ☒ Alternative nicotine products ☒ Vapor products ☒ Type of Establishment: (Select the options that best describe the establishment) Alternative nicotine/vapor store ☐ Bar ☐ Convenience store/gas station ☒ Drug store ☐ Grocery store ☐ Hotel/motel ☐ Liquor store ☐ Restaurant ☐ Tobacco store ☐ Other (provide description) ☐_____________________________________________________ Do you have other permits issued under Iowa Code chapter 453A? If yes, provide permit number(s): YES, CASEY'S HAS 557 LOCATIONS IN IOWA HOLDING A TOBACCO LICENSE. Include with this application a list of your suppliers and customers on a separate sheet. Identify partners or corporate officers if the business is not a sole proprietorship. Name: SEE ATTACHED Title: ____________________________ Address: ____________________________________________ City: ____________________________ State: ____________ ZIP: ____________ Name: ____________________________ Title: ____________________________ Address: ____________________________________________ City: ____________________________ State: ____________ ZIP: ____________