DO NOT STAPLE
                          New Hampshire  
                                                                   DP-31
                            Department of                                                      *00DP312411862*
                    Revenue Administration                                                                          00DP312411862
                                               APPLICATION FOR TOBACCO TAX LICENSE 
                                                                  Manufacturers & Wholesalers
Check A or B as applicable
                                                             Current License #:                                 Manufacturer       Wholesaler
A.       NEW LICENSE                        B.   RENEWAL

C.   Tobacco Products Sold (Dheck all applicable)
                                                                                   % Indicate if you sell any tobacco products from /PO 
            Cigarettes      Little Cigars         Cigars                             1BSUJDJQBUJOH .BOVGBDUVSFST  /1.  VOEFS UIF .BTUFS 
            Loose           E-Cigarettes          Smokeless                          4FUUMFNFOU "HSFFNFOU  .4" 
            Other:                                                                                              Yes  No

1. Business Name (DBA)                                                                         2. Name of Entity  TFF JOTUSVDUJPOT 

3. Business Address Number & Street

4. City/Town                                                       State     Zip Code
                                                                    
5. Mailing Address Number & Street                                                                  6. E-mail Address

7. City/Town                                                       State     Zip Code + 4 (or Canadian Postal Code)
                                                                    
8. Business Phone Number             9. Purchase/Established Date   10. Previous Owner/Business Name

10(a) Type of Business Entity:   Proprietorship             Corporation                Partnership                    Fiduciary      Non-Profit

10( ) C 'JMM JO UIF DPSSFDU UBYQBZFS JEFOUJGJDBUJPO OVNCFS GPS UIF FOUJUZ SFRVFTUJOH B MJDFOTF 
'&*/                                                44/                                        DIN

10(D) List the names of all entities that you buy tobacco products from that have a NH Wholesaler Tobacco Tax License or NH Manufacturer Tobacco 
       Tax License (attach separate sheet if additional space is needed):

10(E ) List all the states where you hold a wholesaler/distributor tobacco license (attach separate sheet if additional space is needed)  
.645 #& $0.1-&5&% #: 8)0-&4"-&34

10(F ) Are you a first importer?          Yes     No
If yes, include a copy of your federal importer license and a listing of all tobacco products you import. 
11. List individual owners, officers, partners, or members (attach a list of additional owners, officers, partners, or members if additional space
is needed):
11(a)Last Name                                           First Name                                             MI   Title

     Residence Address - No PO Boxes                                                           Social Security Number

     City / Town                                            State          Zip Code + 4 (or Canadian Postal Code)    Phone Number
                                                             
       DP-31                                                                                                                            Page 1 of  
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                 New Hampshire  
                                                        DP-31
                      Department of                                          *00DP312421862*
                Revenue Administration                                                                         00DP312421862

                              A11-*$"5*0/ '03 50#"$$0 5"9 -*$&/4&  continued 
11(b) Last Name                                     First Name                                MI                    Title

Residence Address - No PO Boxes                                              Social Security Number

City / Town                                            State            Zip Code + 4 (or Canadian Postal Code)      Phone Number
                                                        
12. License Fees:
Manufacturer:          Fee is $100.00                   $

Wholesaler:               Fee is $250.00                $

Total Amount Enclosed                                   $

      The appropriate fee(s), as listed in Line 12, must accompany this form.
      Make Check Payable to:  STATE OF NEW HAMPSHIRE

13. RSA 78:9, I requires the Commissioner to consider the following information prior to issuing or renewing a Tobacco Tax License.

13(a) Did the applicant previously have a NH Tobacco Tax License revoked under RSA 78:20?     Yes                              No
13(b) Does the applicant or any interest holder in the applicant owe any taxes, interest or penalties to the State  
            of NH under any other tax administered by the department, or any fees, fines or penalties resulting from             Yes     No
      violations of RSA 78 or RSA 126-K? 
13(c) Has the applicant or any interest holder in the applicant been convicted of a crime related to Tobacco Tax or a crime  
      involving theft or fraud in this or any state within the past 2 years?                                                         Yes   No

14. This application must be signed by an owner, officer, partner, or member in ink and dated.
I hereby certify that the above information is true and correct and in conformity with applicable State laws. I am aware that failure to comply 
with the requirements of RSA 78, REV 1000, RSA 541-C,  and RSA 541-D may result in suspension or revocation of the license issued pursuant 
to this application. If signed by a corporate officer, partner, or member on behalf of the manufacturer or wholesaler, I certify that I have the 
authority to legally execute this application on behalf of the licensee.
Signature of Taxpayer  JO JOL                                  MMDDYYYY                       Phone Number

Print Signatory Name & Title

                                File online at Granite Tax Connect HUD SFWFOVF OI HPW 5"1 @ 
                                         or mail to NH DRA PO Box 637, Concord NH 03302-0637  
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DP-31                           Enclose, but do not staple or tape your payment with this application                                    Page 2 of