E-5 - Tobacco Licenses Approval

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. I 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. Signature of Owner(s), Partner(s), or Corporate Official(s) Printed name: DOUGLAS BEECH, ASSISTANT SECRETARY Printed name: __________________________ Signature: __________________________ Signature: __________________________ Date: 04/01/2024 Date: __________________________ Printed name: __________________________ Signature: __________________________ Date: __________________________ 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: $75 • Fill in the date the permit was approved by the council or board: __________________________ • Fill in the permit number issued by the city/county: __________________________ • Fill in the name of the city or county issuing the permit: __________________________ • New ☐ Renewal ☒ Send completed/approved application to the Iowa Department of Revenue within 30 days of issuance. Make sure the information on the application is complete and accurate. A copy of the permit does not need to be sent; only the application is required. If a permit is being exchanged due to change of location within the same jurisdiction, permittee should complete an application with new 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: [email protected] • Fax: 515-281-7375