E-5 - Tobacco License Renewal - Casey's

Iowa Retail Permit Application for Cigarette/Tobacco/Nicotine/Vapor https://tax.iowa.gov Instructions on the reverse side For period (MM/DD/YYYY) 07/01/22 through June 30, 2023 I/we apply for a retail permit to sell cigarettes, tobacco, alternative nicotine, or vapor products: Business Information: Trade Name/DBA CASEY'S MARKETING COMPANY/DBA CASEY'S #2667 Physical Location Address 403 STEPHANS ST—City TIFFIN ZIP52340—Mailing Address PO BOX 3001 City ANKENY State IA ZIP 50021 Business Phone Number 3195454402 Legal Ownership Information: Type of Ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☒ LLC ☐ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or LLP CASEY'S GENERAL STORES, INC. Mailing Address PO BOX 3001 City ANKENY State IA ZIP 50021 Phone Number 515-381-5974 Fax Number 515-446-6303 Email [email protected] Retail Information: Types of Sales: Over-the-counter ☒ Vending machine ☐ Do you make delivery sales of alternative nicotine or vapor products? (See Instructions) Yes ☐ No ☒ Types of Products Sold: (Check all that apply) Cigarettes ☒ Tobacco ☒ Alternative Nicotine Products ☒ Vapor Products ☒ Type of Establishment: (Select the option that best describes the establishment) Alternative nicotine/vapor store ☐ Bar ☐ Convenience store/gas station ☒ Drug store ☐ Grocery store ☐ Hotel/motel ☐ Liquor store ☐ Restaurant ☐ Tobacco store ☐ Has vending machine that assembles cigarettes ☐ Other ☐ If application is approved and permit 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. Signature of Owner(s), Partner(s), or Corporate Official(s) Name (please print) DOUGLAS BEECH, AST. SECRETARY CASEY'S MARKETING Signature Douglas M. Beech Date 4/1/2022 Send this completed application and the applicable fee to your local jurisdiction. If you have any questions contact your city clerk (within city limits) or your county auditor (outside city limits). FOR CITY CLERK/COUNTY AUDITOR ONLY – MUST BE COMPLETE • Fill in the amount paid for the permit: $75 ck 343+35 • 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: City of Tiffin • New ☐ Renewal ☒ Send completed/approved application to Iowa Alcoholic Beverages Division 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. 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