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Wyoming Department of Revenue *0-0-0-007*
122 W 25 thSt STE E301 *0-0-0-007*
Herschler Building East
Cheyenne, WY 82002-0110
Web site: http://revenue.wyo.gov Department Use Only

License No:______________

Cigarette Wholesalers, Cigarette Importer, Cigarette Manufacturer,
and Nicotine Products Wholesaler License Application

1. Date business began wholesaling cigarettes and/or other tobacco products in Wyoming: ______________________

2. Ownership Name:______________________________________________________________________________

3. Doing Business Name or DBA:____________________________________________________________________

4. Type of Ownership: Individual Partnership Corporation Association or Other ____________________
Specify

5. Business Phone Number: ( ) - Fax Number: ( ) -

6. Business Location:________________________________________________________________________
Street Address City State Zip

7. Mailing Address: ________________________________________________________________________
Street Address City State Zip
8. Do you purchase unstamped cigarettes directly from a manufacturer for sale or resale in Wyoming? Yes No

9. Do you purchase cigars, snuff, or other tobacco products directly from a manufacturer for sale or resale in Wyoming?
Yes No

10. Do you purchase electronic cigarettes and vapor material products directly from a manufacturer for sale or resale in
Wyoming? Yes No

11. Are you a cigarette importer who imports into the United States either directly or indirectly a finished cigarette for
sale or distribution in Wyoming? Yes No

12. Are you a cigarette manufacturer who manufactures, fabricates, assembles, processes or labels a finished cigarette for
sale in Wyoming? Yes No

13. Are you an other tobacco products manufacturer who manufactures, fabricates, assembles, processes or labels other
tobacco products for sale in Wyoming? Yes No

14. Are you a manufacturer of electronic cigarettes and vapor material who manufacturers, fabricates, assembles,
processes or labels electronic cigarettes and vapor material for sale in Wyoming? Yes No

15. Do you sell at retail stamped cigarettes, electronic cigarettes, vapor material or other tobacco products directly to
Wyoming consumers? Yes No If yes, you must also obtain a Wyoming Sales/Use Tax License Number. WY
Sales Tax License No.:

16. Do you sell roll your own tobacco? Yes No

Note: Original Signature(s) are required for all ownership types. The business owner must sign for the individual
ownership, all partners must sign for partnerships, one major officer for a Corporation, one member or manager for a
Limited Liability Company and two partners for Limited Partnership. Attach an additional signature page if needed.
Signatures must be original.

Signature________________________________Title_________________________________Date_________________

A license is required for each business location. A Ten dollar ($10.00) License Fee must accompany each application. Remittance to
be made payable to: Department of Revenue

ETS Form 002(revised 5/11/2020)

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               NOTICE TO WYOMING LICENSED TOBACCO WHOLESALERS 
 
   Please identify whether as a Wyoming Department of Revenue Licensee you will be engaging in any of 
the following: 

  Paying tobacco tax to the Wyoming Department of Revenue on roll-your-own tobacco, under W.S. 39-
   18-103(a)(iii) 
  Adhering tax stamps to cigarette packs or otherwise paying tobacco tax to the Wyoming Department of 
   Revenue on cigarettes, under W.S. 39-18-103(a)(i) 
  Importing or distributing within the State cigarettes or roll-your-own tobacco to retailers 
  Selling or distributing for sale or resale within the state cigarettes or roll-you-own tobacco   over the 
   internet or through any other means of direct or indirect mail solicitation or delivery to any 
   person in the State 

   If you have checked any of the boxes above, you must submit monthly reporting to the Wyoming 
Attorney General through   www.certivault.com. If you do not already have an account through Certivault, you 
must register for your account by emailing support@certivault.com. 

   If you have not checked any of the boxes above, you are certifying that are not engaging in and will not 
engage in sales or activities that require tobacco tax payment under W.S. 39-18-103(a)(i) or (iii). If this status 
changes at any point while you are a licensee, you must immediately report that change to the Wyoming 
Attorney General, Tobacco Settlement Unit.  

Signing this form attests to the Department of Revenue your compliance with W.S. 9-4-1202 and 9-4-1205 
through 9-4-1211 and to your compliance with the Tobacco Certification and Directory Rules (available at 
www.ag.wyo.gov/tobacco-settlement-unit). Once signed, return this form to the Department of Revenue on or 
before the stipulated deadline.  
I certify under penalty of false swearing, that I have read this form, and shall comply with the W.S. 9-4-1201 
through 9-4-1211 and all relevant rules. 
 
______________________________ 
Wholesaler License Number 

______________________________ 
Address (city, state, zip) 

______________________________                                   _____________________ 
Signature of Authorized Representative                           Date 

______________________________                                   ___________________________________ 
Name of Authorized Representative                                Title of Authorized Representative

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Cigarette & OTP Wholesalers, Importers and Manufacturer
License Application Instructions

# Requested Information Description

1 Date you began wholesaling in This is the date of your first wholesale transaction in Wyoming, or the date
Wyoming you will start your business. It can be a future date.

2 Ownership Name This is the name of the ownership of the business or the legal name of the
business. It is the name of the corporation, LLC, partners in the partnership,
or your name if you are a sole proprietor. Example: ABC Suppliers Inc

3 DBA/Doing Business As Name This is the name people will use to identify your business. It is sometimes
referred to as your trade name. It can be how you list your business in the
telephone book or on business cards. Example: ABC Widgets and Gidgets.

4 Type of Ownership This goes along with the Ownership name and should be consistent. If your
ownership name is ABC Suppliers Inc, you should select Corporation. Date
and State of Incorporation should be completed by all corporations and
LLC’s.

5 Business Phone Number The phone number associated with your business, along with a toll free
number or fax number if you have them.

6 Business location address This is the location of your business. It cannot be a registered agent or virtual
office address. If you do not have a physical storefront, it needs to be the
address where your business records can be inspected or where your
customer can return an item. It may be your home address if you run an
online store, attend various craft shows, have a food truck, or similar
businesses.

7 Mailing Address The address we will use when mailing your tax returns, license certificate,
quarterly newsletters and any time sensitive notices from us.

8 Do you purchase unstamped If yes, this allows you to purchase stamps from our department. It also
cigarettes directly from a allows you to stamp product for resale.
manufacturer for sale or resale This requires you to file a monthly form 70 tobacco return.
in Wyoming?

9 Do you purchase cigars, snuff, If yes this means you are a wholesaler of other tobacco product (ie: chew,
or other tobacco products cigars, moist snuff etc.)
directly from a manufacturer for This requires you to file a quarterly form 71 tobacco return.
sale or resale in Wyoming?

10 Do you purchase If yes, this means that you purchase electronic cigarettes and vapor products
electronic cigarettes and for sale or resale.
vapor material products
directly from a
manufacturer for sale or
resale in Wyoming?

11 Are you a cigarette importer If yes, this means that you import product in the United States including
who imports into the United Wyoming.
States either directly or There are no filing requirements except a yearly renewal of this license.
indirectly a finished cigarette
for sale or distribution in
Wyoming?

12 Are you a cigarette If yes, this means that you manufacture cigarettes that is then sold to a
manufacturer who tobacco wholesaler.
manufactures, fabricates, There are no filing requirements except a yearly renewal of this license.
assembles, processes or labels a
finished cigarette for sale in
Wyoming?

13 Are you an other tobacco If yes, this means that you manufacture other tobacco product that you sell to
products manufacturer who a tobacco wholesaler.
manufactures, fabricates, There are no filing requirements except a yearly renewal of this license.
assembles, processes or labels
other tobacco products for sale
in Wyoming?

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14 Are you a manufacturer of If yes, this mean you manufacture, fabricate, assemble, process or label
electronic cigarettes and electronic cigarettes and vapor material.
vapor material who
manufacturers, fabricates,
assembles, processes or
labels electronic cigarettes
and vapor material for sale in
Wyoming?

15 If yes, you must have a Wyoming Sales Tax License. If any of the 8-14
Do you sell at retail stamped
questions were no then you do not need a Tobacco License but will need a
cigarettes, electronic cigarettes
and vapor material or other Wyoming Sales Tax License. Visit our website at http://revenue.wyo.gov
tobacco products directly to to download the application.
Wyoming consumers?

16 Do you sell roll your own If you sell tobacco that can be used to roll your own cigarette then you would
tobacco? mark yes. If you do not sell tobacco that would be used to roll your own
cigarette then mark no.

17 Signature Block The signature and title of the responsible parties for the business. If a sole
proprietor, we require the owner’s signature and title. If a partnership, we
require each partner’s signature and title. If a corporation, we require at least
one major officer’s signature and title (President, Vice President, Treasurer,
Secretary). If an LLC, we require at least one member or manager’s
signature and title. If a Limited Liability Partnership, we require signatures
and titles of at least two partners.

nd
Read, sign the application and proceed to the 2 page titled Notice to Wyoming Licensed Tobacco Wholesalers.
This page quotes Wyoming Statute 39-18-106(a). This form must be read and signed by ALL applicants in
addition to the application and submitted with the application to:

WYOMING DEPARTMENT OF REVENUE
122 W 25TH ST STE E301
HERSCHLER BUILDING EAST
CHEYENNE WY 82002-0110
If you have any questions in completing this application please contact our office at 307-777-5541.

ETS Form 002(revised 5/11/2020)

PDF file checksum: 3450518738

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