Form 150-105-001 "Application for Distributor/Wholesaler License" - Oregon

What Is Form 150-105-001?

This is a legal form that was released by the Oregon Department of Revenue - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the Oregon Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 150-105-001 by clicking the link below or browse more documents and templates provided by the Oregon Department of Revenue.

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Download Form 150-105-001 "Application for Distributor/Wholesaler License" - Oregon

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Clear Form
Application for
Office use only
Distributor / Wholesaler
Date received
BIN
License
Cigarette license number
Date license issued
Cigarette distributor
Tobacco license number
Approved by
Tobacco products distributor
• You must also complete
Cigarette wholesaler
the back of this form.
Business name
Business registry number
Federal employer ID number (FEIN)
City
County
State
ZIP code
Physical street address
Phone
Mailing address
City
ZIP code
State
(if different from above)
(
)
Physical location of business records
City
ZIP code
Phone
State
(
)
Fax number for business records
Contact person
Phone
(
)
(
)
Date business started
Type of organization
Individual
Partnership
Corporation
S Corporation
Other: ____________________
Names of owners, partners, shareholders, or corporation officers:
Street address
City, State, ZIP code
Social Security number
Name
Employer status
Are you an employer?
Yes (nonexempt)
No (exempt*)
If yes, you must provide:
WCD seven-digit compliance number OR name of carrier and policy number: _________________________________________
*All-family business may be exempt form workers’ compensation. Contact the Workers’ Compensation Division to determine eligibility, 503-947-7815.
Nature of business
Manufacturer
Common carrier
Wholesaler
Within Oregon
Internet sales
Distributor
Retailer
Importer
Outside Oregon
Other: ______________________
Source of product supply
Manufacturer’s warehouse stock
Imported direct from outside Oregon
Manufactured in Oregon
From other licensed distributors
Cigarette tax stamps
Method of payment:
Cash
or
Deferred payment
(requires deposit of a bond)
Method of shipment:
Pick-up or
Courier: Name _________________________ Courier account no. _____________
Average number of cigarettes (with Oregon stamps) to be distributed during the year: _______________________
Contact person’s name and telephone number: ____________________________________________________________________
Additional information on the back
150-105-001 (Rev. 09-17)
Mail completed application to: Cigarette/Tobacco Tax
Oregon Department of Revenue
PO Box 14630
Salem OR 97309-5050
Clear Form
Application for
Office use only
Distributor / Wholesaler
Date received
BIN
License
Cigarette license number
Date license issued
Cigarette distributor
Tobacco license number
Approved by
Tobacco products distributor
• You must also complete
Cigarette wholesaler
the back of this form.
Business name
Business registry number
Federal employer ID number (FEIN)
City
County
State
ZIP code
Physical street address
Phone
Mailing address
City
ZIP code
State
(if different from above)
(
)
Physical location of business records
City
ZIP code
Phone
State
(
)
Fax number for business records
Contact person
Phone
(
)
(
)
Date business started
Type of organization
Individual
Partnership
Corporation
S Corporation
Other: ____________________
Names of owners, partners, shareholders, or corporation officers:
Street address
City, State, ZIP code
Social Security number
Name
Employer status
Are you an employer?
Yes (nonexempt)
No (exempt*)
If yes, you must provide:
WCD seven-digit compliance number OR name of carrier and policy number: _________________________________________
*All-family business may be exempt form workers’ compensation. Contact the Workers’ Compensation Division to determine eligibility, 503-947-7815.
Nature of business
Manufacturer
Common carrier
Wholesaler
Within Oregon
Internet sales
Distributor
Retailer
Importer
Outside Oregon
Other: ______________________
Source of product supply
Manufacturer’s warehouse stock
Imported direct from outside Oregon
Manufactured in Oregon
From other licensed distributors
Cigarette tax stamps
Method of payment:
Cash
or
Deferred payment
(requires deposit of a bond)
Method of shipment:
Pick-up or
Courier: Name _________________________ Courier account no. _____________
Average number of cigarettes (with Oregon stamps) to be distributed during the year: _______________________
Contact person’s name and telephone number: ____________________________________________________________________
Additional information on the back
150-105-001 (Rev. 09-17)
Mail completed application to: Cigarette/Tobacco Tax
Oregon Department of Revenue
PO Box 14630
Salem OR 97309-5050
Additional information required
What is the nature of your business that requires an Oregon license?
In what area (cities) do you plan to distribute in Oregon?
List the name, address, and telephone number of your suppliers:
(attach additional pages as necessary)
1.
4.
2.
5.
3.
6.
List each manufacturer’s name and the warehouse address from which you receive your supply:
(attach additional pages as necessary)
Manufacturer’s name
Warehouse address
City, State, ZIP code
Identify other licenses issued to you for cigarette and tobacco products for any other state:
(attach additional pages as necessary)
Type of license (cigarette, tobacco products, etc.)
State
Will you use Oregon cigarette tax stamps on products that you distribute?
Yes
No. If yes, explain how and where you will af-
fix the stamps for distribution.
Does the business being conducted violate any Oregon law?
Yes
No
Have you (applicant), or any other person listed on this application, ever been denied a permit, license, or other authorization to engage
in any business to manufacture, export, or import tobacco products by any government agency (federal, state, local, or foreign), or had
such permit, license, or other authorization revoked, suspended, or otherwise terminated?
Yes
No. If yes, you must explain.
Consent to search for contraband product
For the purpose of enforcing Oregon’s cigarette tax and anti-contraband cigarette laws, I hereby consent to the inspection and examination by
the Oregon Department of Revenue and its authorized agents of any books, records (including Oregon cigarette tax stamps), receipts, invoices,
equipment relating to cigarettes; cigarette packs, cigarette cartons; or any other storage container designed or used to store cigarettes or any
other pertinent document or equipment related to the sale, purchase, storage, tax stamp application, or transportation of cigarettes.
Federal Privacy Act Information
Under the general authority of OAR 150-305-0010, the Social Security numbers of all company officers of distributorships must be included in
the application for a distributor’s license. This information is to be used primarily by the Oregon Department of Revenue for identification and
compliance purposes in the administration of the Oregon Cigarette Tax Act and the Oregon Tobacco Products Tax Act. Oregon law permits
disclosure of such information to governmental units outside Oregon, which also tax tobacco products and which grant reciprocal rights.
Signing this application acknowledges awareness of the requirements of the Jenkins Act (Title 15, U.S.C. Sect. 375 et. seq.). This act requires
distributors to file reports with the taxing authority of the state where cigarettes are shipped to persons other than another licensed distributor.
The report must include the total number of cigarettes shipped, and the complete name and address of the person receiving the cigarettes.
I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document and to the best of my knowledge, it is
true, correct, and complete.
Social Security number
Signature
Title
Date
150-105-001 (Rev. 09-17)
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