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State Tax Application For Tobacco Permit ATT-12 - Georgia
| State Tax Application For Tobacco Permit Form. This is a Georgia form and can be used in Alcohol And Tobacco Division Department Of Revenue Statewide . |
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ATT-12 (Rev. 5/11) GEORGIA DEPARTMENT OF REVENUE ALCOHOL & TOBACCO DIVISION P O BOX 49728 ATLANTA GA 30359 (404) 417-4870 FOR OFFICE USE ONLY STATE TAX APPLICATION FOR TOBACCO PERMIT (Read Instructions Before Completing) 1. STATE TAXPAYER IDENTIFIER (STI) 2. LEGAL BUSINESS NAME BUSINESS ADDRESS 3. TYPE OF APPLICATION [ ] MANUFACTURER REPRESENTATIVE LICENSE 4. SOCIAL SECURITY NO. 5. HOME ADDRESS 6. CITY 7. MAILING ADDRESS (If different from home address) 8. BUSINESS PHONE NO. TOBACCO LICENSE NUMBER [ ] WHOLESALER SALESMAN PERMIT DATE OF BIRTH LAST, FIRST, MIDDLE INITIAL OF APPLICANT STATE ZIP CODE HOME PHONE NO. 9. HOW LONG HAVE YOU BEEN EMPLOYED BY ABOVE MANUFACTURER / DISTRIBUTOR? 10. PROVIDE YOUR EMPLOYMENT HISTORY FOR THE PAST TEN (10) YEARS FROM Month/Yr. EMPLOYER'S NAME AND ADDRESS POSITION 11. HAVE YOU EVER BEEN ARRESTED OR HELD BY FEDERAL, STATE, OR ANY OTHER LAW-ENFORCEMENT AUTHORITIES FOR ANY VIOLATION OF FEDERAL LAW, STATE LAW, COUNTY, OR MUNICIPAL LAW, REGULATION, OR ORDINANCES? (Do not include traffic violations. All other charges must be included even if they were dismissed) [ ] YES [ ] NO ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ___________________________________________________________________________ I DECLARE UNDER PENALTY OF PERJURY THAT THIS STATEMENT HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE IS TRUE, CORRECT AND COMPLETE. ______________________________________ Signature Title ______________________ Date I HEREBY CERTIFY THAT __ __________________________ IS PERSONALLY KNOWN TO ME, THAT HE SIGNED HIS NAME TO THE FOREGOING APPLICATION AFTER STATING TO ME THAT HE KNEW AND UNDERSTOOD ALL STATEMENTS AND ANSWERS MADE THEREIN, AND UNDER OATH ACTUALLY ADMINISTERED BY ME, HAS SWORN THAT SAID STATEMENTS AND ANSWERS ARE TRUE. THIS__________ DAY OF ___________________________, _________________ _____________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com Affidavit of Compliance with O.C.G.A. 50-36-1 "Verification of Lawful Presence within the United States" O.C.G.A. 50-36-1 requires that applicants applying for such things as licenses for public benefits complete a signed and sworn affidavit verifying the applicant's lawful presence in the United States. Therefore, the applicant must answer the following questions: The applicant is a United States citizen or legal permanent resident at least eighteen (18) years old. Yes ______ No ______ The applicant is a qualified alien or nonimmigrant under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, at least eighteen (18) years old, and is lawfully present in the United States. The applicant's alien number issued by the Department of Homeland Security or other federal immigration agency must be provided. Yes ______ No ______ Alien Number ____________________________________ O.C.G.A 50-36-1 states that "Any person who knowingly and willfully makes a false, fictitious, or fraudulent statement of representation in an affidavit executed pursuant to this Code section shall be guilty of a violation of Code Section 16-10-20." I declare, under penalty of law, that this affidavit has been completed by me and is true and correct. ___________________________________________________________________________________________ Signature Title Date (Must be signed by applicant. If the applicant is a corporation, must be signed by an officer of the corporation. STAMPED SIGNATURE IS NOT ACCEPTABLE) I hereby certify that__________________________________________________________ is personally known, or verified by me, that the applicant signed this application after stating to me his or her personal knowledge and understanding of all statements and, under oath actually administered by me, has sworn that the statements and answers contained in this affidavit are true. This _________ day of _____________, ______ . AFFIX SEAL _______________________________________ Notary Public You must attach a copy of a secure and verifiable document as defined in O.C.G.A. 50-36-2. Such documents include a valid Georgia issued Driver's License or ID Card, a valid Driver's License issued by another State or an identification document issued by the United States Government. American LegalNet, Inc. www.FormsWorkFlow.com
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