E-4 - Tobacco License Renewal - Morgan's Service

Iowa Retail Permit Application for Cigarette/Tobacco/Nicotine/Vapor https://tax.iowa.gov Instructions on the reverse side For period (MM/DD/YYYY) 6/30/21 through June 30, 2022 I/we apply for a retail permit to sell cigarettes, tobacco, alternative nicotine, or vapor products: Business Information: Trade Name/DBA Morgan's Service LLC Physical Location Address 230 W Marengo Rd City Tiffin ZIP 52340 Mailing Address PO Box 169 City Tiffin State IA ZIP 52340 Business Phone Number 319-545-2021 Legal Ownership Information: Type of Ownership: Sole Proprietor ☐ Partnership ☐ Corporation ☐ LLC ☒ LLP ☐ Name of sole proprietor, partnership, corporation, LLC, or LLP Morgan's Service LLC Mailing Address PO Box 169 City Tiffin State IA ZIP 52340 Phone Number 319-545-2021 Fax Number 319-545-5109 Email Skeetman@SouthSlopeInc. 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 ☒ Automotive Repair 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) Tom Morgan Signature Tom Morgan Date 6/1/21 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: $75.00/1080 • 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 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