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Wyoming Department of Revenue *0-0-0-007*
Herschler Building *0-0-0-007*
122 West 25 thStreet
Cheyenne, WY 82002-0110
Web site: http://revenue.wyo.gov
Department Use Only
License No:______________
Date Issued:_____________
Cigarette Wholesalers & Other Tobacco Wholesalers, Cigarette
Importer, Cigarette Manufacturer 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. 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
11. Are you a cigarette manufacturer who manufactures, fabricates, assembles, processes or labels a finished cigarette for
sale in Wyoming? Yes No
12. Are you an other tobacco products manufacturer who manufactures, fabricates, assembles, processes or labels other
Tobacco Products for sale in Wyoming? Yes No
13. Do you sell at retail stamped cigarettes or other tobacco products directly to Wyoming consumers? Yes No
If yes, indicate your Wyoming Sales/Use Tax License Number
14. 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_________________
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 (5/7/19)
