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): Fareway Stores, Inc. #193 Iowa sales and use tax account number: 152026304 Retail address: 500 Croell Ave City: TIFFIN State: IA ZIP: 52340 Mailing address: PO Box 70, Attn: Tracey Wilson City: Boone State: IA ZIP: 50036 Phone: 319-645-2126 Legal Ownership Information: Type of ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☒ LLC ☐ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or LLP: Fareway Stores, Inc. Primary office address: 715 8th St, PO Box 70 City: Boone, ________ State: IA ZIP: 50036 Phone: 515-433-5336 Fax: 515-433-4416 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): NA 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 Schedule #1** Title: ____________________________ Address: _______________________________________________________ City: ____________________________ State: __________ ZIP: __________ Name: ____________________________ Title: ____________________________ Address: _______________________________________________________ City: ____________________________ State: __________ ZIP: __________