State of New Jersey
Division of Revenue
P O Box 252
Trenton, N.J. 08625
LICENSE APPLICATION
Mail Name and Address
S treet
City S tate Zip Code
Complete the information below which pert ains to the specific license.
B. Motor Fuel Ret ail Dealers License
Number of pumps . . . . . . . . . __________________________ Capacity in gallons/GASOLINE _________________________
Name of supplier . . . . . . . . . . __________________________ Capacity in gallons/DEISEL ____________________________
Do you sell diesel? . . . . . . . . __________________________ Brand sold . . . . . . . . . . ______________________________
C. Motor Fuel Transport License (Transport License Plates are not Transferable)
State License Plate Number . __________________________ Make of vehicle . . . . . . ______________________________
V ehicle identification number . __________________________
Barge name . . . . . . . . . . . . . __________________________ Year . . . . . . . . . . . . . . . ______________________________
D. Cigarette Manufacturer Represent ative License
Name of company you represent _____________________________________________________________________________
E. Cigarette Ret ail Over-The-Counter License
Name of company where you purchase your cigarettes ____________________________________________________________
F. Cigarette Vending Machine License
Number of machines you are applying for _________________________ (Enclose a $50.00 fee for each machine)
Name of company where you purchase your cigarettes ____________________________________________________________
Y ou must att ach a list with the physical address of each vending machine
Business Location Address
S treet
City S tate Zip Code
CM-100
(12-08)
OFFICIAL USE ONLY
DLN
P L ATE NO.
CHECK ONE BOX COMPLETE INFORMATION BELOW ENCLOSE FEE
¨ Motor Fuel Ret ail Dealers License (three (3) year license) (complete A & B below) . . . . . . . . . . . . . . . . . . . $ 150.00
¨ Motor Fuel T ransport License (complete A & C below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00
¨ Cigarette Manufacturer Represent ative License (one (1) year license) (complete A & D below) . . . . . . . . . . $ 5.00
¨ Cigarette V ending Machine License (one (1) year license) (complete A & F below) . . . . . . . . . . . . . . . . . . . $ 50.00
¨ Cigarette Ret ail Dealers Over-the-Counter License (one (1) year license) (complete A & E below) . . . . . . . . $ 50.00
IMPORTANT:A separate application with a s e p arate check must be submitted for each license type.
A. All applicant s must complete Part A
Federal Identification Number ___ ___ - ___ ___ ___ ___ ___ ___ ___
¨ Check box if this is a license renewal
Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Name ___________________________________________________________________________________________________
(Corporate, p artners, proprietor , represent ative)
Trade Name ______________________________________________________________________________________________
TYPE OF OWNERSHIP
¨ Corporation ¨ Proprietorship ¨ Partnership ¨ Representative ¨ Other ___________________________
Date business began in New Jersey _______ / _______ / _______ Cont act Telephone Number ( ) _______ - ____________
M o Day Yr
OWNER INFORMATION
Name Title Social Security No. Home Address
________________________________ ___________________ _______/______/_______ _______________________________________
________________________________ ___________________ _______/______/_______ _______________________________________
________________________________ ___________________ _______/______/_______ _______________________________________
Signature ________________________________________________________________ Date __________________________________________
All appropriate information must be completed and the application must have an authorized signature to be processed.
FEE MUST ACCOMPANYAPPLICATION
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Make Checks Payable To: State of New Jersey
