E-4 - Cigarette Licenses Renewals

Additional instructions are on the final page. For period (MM/DD/YYYY) 07 / 01 / 2025 through 06/30/2026 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): Kum & Go #137 Iowa sales and use tax account number: 152022420 Retail address: 101 Village Dr City: Tiffin State: IA ZIP: 52340 Mailing address: 1150 Locust St. Suite 301 City: Des Moines State: IA ZIP: 50309 Phone: 515-274-7793 Legal Ownership Information: Type of ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☐ LLC ☒ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or LLP: Kum & Go LC Primary office address: 1150 Locust St. Suite 301 City: Des Moines State: IA ZIP: 5039 Phone: 515-274-7793 Fax: 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 at this retail location? If yes, provide permit number(s): No Do you intend to make retail sales to ultimate consumers? Yes ☒ 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: Crystal Maggelet Title: President Address: 185 South State Street Suite 800 City: Salt Lake City State: UT ZIP: 84111 Name: Tyler Call Title: Vice President