2. Application for Iowa Retail Cigarette / Tobacco Permit
4. For period through
   For period through Start Date

   —

   For period through End Date
6. Please submit this completed application to your local jurisdiction. If you have questions, call your city Clerk (within city limits) or your County Auditor (outside city limits).
   I/We hereby make application for a retail permit to sell cigarettes and tobacco products.
8. Business Information
10. Name of Business / DBA
12. Location Address*
14. Location City*
15. Location State*
16. Location Zip Code*
18. Mailing Address
20. Mailing City
21. Mailing State
22. Mailing Zip Code
24. Telephone Number
26. Type of Sales:

    1. Over-the-Counter
    2. Vending Machine
27. Type of Retail Establishment

    1. Bar
    2. Convenience Store - No Gas
    3. Convenience Store - With Gas
    4. Drug Store
    5. Gas Station

    1. Grocery
    2. Hotel/Motel
    3. Liquor Store
    4. Restaurant
    5. Tobacco Store
29. Cigarettes must be sold at the minimum price set by the State of Iowa.
    Obtain a current copy from the Iowa Department of Revenue website, or from TaxFax at 800-572-3943 (enter form number 71023).
31. Only approved brands of cigarettes or roll-your-own products may be sold in Iowa.
    Any brand not on the list is contraband. In addition, all cigarettes sold in Iowa must have an Iowa Cigarette Tax Stamp affixed to each package. Any violation of contraband or non-Iowa cigarette tax stamped package is subject to seizure and penalties under the provisions of Iowa Code 453A and 453D.
33. The list of approved brands is always current at The Iowa Department of Revenue website (PDF).
    The list of approved brands is called Iowa Directory of Certified Tobacco Products Manufacturers - Their Brands and Brand Families.
35. Sign up for the Cigarette/Tobacco E-List.
    You will receive an e-mail every time the approved list changes or the minimum price changes.
37. Legal Owner Information
39. Type of Ownership

    1. Corporation
    2. Individual
    3. LLC
    4. LLP
    5. Partnership
    6. Other (If other, please fill out type)
40. Other
    If you choose Other as Type of Ownership, write in type of ownership.
42. Legal Owner
    Name of Corporation, Individual, LLC, LLP, or Individual
44. Mailing Address
46. Mailing City
47. Mailing State
48. Mailing Zip Code
50. Phone Number
51. Fax Number
53. Email Address
55. If application is approved and permit granted, I/we do hereby bind ourselves to a faithful observance of laws governing the sale of cigarettes and tobacco products.
57. E-Signature*
58. Date
    Date
63. Instructions for Iowa Retail Cigarette / Tobacco Permit Application
    Cigarettes must be sold at the minimum price set by the State of Iowa. Obtain a current copy of the minimum price list from the Iowa Department of Revenue website at or from the TaxFax system at 1-800-572-3943 (enter form number 71023).
65. Only Approved Brands of Cigarettes or Roll-Your-Own Products May Be Sold in Iowa
    Any brand not on the list is contraband. In addition, all cigarettes sold in Iowa must have an Iowa Cigarette Tax Stamp affixed to each package. Any violation of contraband or non-Iowa cigarette tax stamped package is subject to seizure and penalties under the provisions of Iowa Code 453A and 453D.
    
    The list of approved brands is always current at the Iowa Directory of Certified Tobacco Products Manufacturers —Their Brands and Brand Families.
    
    Sign up for the Cigarette/Tobacco E-list, and you will receive an e-mail every time the approved list changes or the minimum price list changes.
67. A new application must be submitted every year. A permit will not be issued until the application is properly completed. Fill in the month, day and year that this application covers. All permits expire June 30th. Normally this period will be the Fiscal Year July 1st through June 30th.
69. Business Information
    - Fill in the name the business is known by - DBA (doing business as).
    - Fill in the REQUIRED location and mailing address, city, and zip where the business is actually located, i.e. 911 address. Add the post office box if required for mail delivery.
    - Check whether the cigarettes will be sold through a vending machine or over the counter.
    - Fill in the 10-digit telephone number of the business.
    - Check one type of retail establishment, i.e. bar, convenience store-no gas, convenience-with gas, drug, gas station, grocery, hotel/motel, liquor store, restaurant, tobacco store, other (if “other,” please write in type).
71. Legal Owner Information
    - Check whether the legal ownership of the business is individual, a partnership, a corporation, a Limited Liability Corporation (LLC) or a Limited Liability Partnership (LLP).
    Fill in the name of the individual, the partnership, the corporation, the LLC or the LLP that is the legal owner of the business. This is NOT the store manager or corporate president.
    - Fill in the mailing address, post office box (if required for mail delivery), city, state, zip and telephone number of the above named legal owner.
    - Fill in the fax number and e-mail address of the legal owner.
    - Print the name of the individual owner, partner(s) or corporate official signing this application.
    - Sign and date the application. The application must be signed by the owner, one of the partners or one of the corporate officers listed above. A preparer’s or store manager’s signature is not acceptable unless he/she is one of the owners, partners, or corporate officers.
    - Return this application to your local jurisdiction City Clerk (within city limits) or County Auditor (outside city limits).
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field