Beverly Hills Tobacco Retailer Permit Application

							                                                                   TOBACCO RETAILERPERMIT
                      Required under City of Beverly Hills Municipal Code, Chapter 4 Article 2, Section 21-01
                                               City of Beverly Hills Finance Division
                                                           (310) 285-2424
              Business Tax No. ...
'INTERNALUSE:••.                                                                                                                  Permit No ..
 Please Check Applicable:                       New Application           0        Change of Owner           0         Change of Information        0         _

 Business Name                                                                                                                    Bus. Start Date

 Mailing Name
 (if applicable)
 Business location
                                 (Cannot be a P.O. Box per Stale of California Business and Professions Code - Section 17538.5)


                                                                                                                                  FederallD No.

 Mailing Address                                                                                                                  State ID No.
 (If different than business location)



 phone No.

 Description of Business

 Ownership:             Corporation         0           Corp-ltd Liability 0                 Partnership       0          Sole Proprietor   0       Trust 0
 Enter below names of each Owner, Partner, or Corporate Officer seeking a Tobacco Retailer's Permit (Use additional sheets as necessary.)

 1st Owner Name                                                            Title                                                  Home phone No.

 Home Address                                                                                                                     Cell Phone No.
 (Cannot be a P.O. Box)




 2nd Owner Name                                                             Title                                                 Home Phone No.

 Home Address                                                                                                                     Cell Phone No.
 (Cannot be a P.O. Box)



please enter a single name and address authorized by each proprietor to receive all communications and notices. Ifan
authorized address is not supplied, each proprietor shall be understood to consent to the provisions of notice at the business
address specified above.

Name                                                                                                                              Home Phone No.

Address                                                                                                                           Cell Phone No.

o   Enclose proof (a photocopy of a valid State Tobacco Retailer's license) that the location for which a Tobacco Retailer's
Permit is sought has been issued a valid State Tobacco Retailer's license by the California State Board of Equalization.

Has any proprietor admitted violating or has been found to have violated, or whose proprietorship had admitted violating
or been found to have violated this code section CMC 38-61 through 38-80?      0 Yes ONo
Ifyes, please list the dates and locations of all such violations within the past six years:


Signature of Owner or Representative:                                                                                             Date:

Title:



                                           RETURN APPLICATION WITH PAYMENT & ORIGINAL SIGNATURE TO:
                                         FINANCE DIVISION, 455 N. REXFORD DRIVE, BEVERLY HILLS, CA 90210
                                                     Make Checks Payable To: City of Beverly Hills