17 N.C. Admin Code 04C .0104 - Application or Renewal Requirements for Applicants and Licensees Under Article 2a
(a) A distributor obtaining, renewing, or updating a license pursuant to G.S. 105-113.12 shall use Form B-A-2.
(b) A wholesale dealer or retail dealer obtaining, renewing, or updating a license pursuant to G.S 105-113.36 shall use Form B-A-2.
(c) Form B-A-2 requires the following:
(1) a description of the transactions requested, including:
(A) a designation of whether the applicant or licensee is requesting an initial license, renewing a license, or updating information previously submitted on the form;
(B) the applicant's or licensee's business structure, such as a sole proprietorship, partnership, corporation, limited liability company, limited liability partnership;
(C) if requesting a new license or renewal of an existing license, the type of license requested;
(D) the seven digit number assigned by the North Carolina Secretary of State, if applicable; and
(E) the total payment due;
(2) the applicant's or licensee's business information, including:
(A) information required by 17 NCAC 01C .0322(b);
(B) the legal name;
(C) the date the business began operations;
(D) the trade name or doing-business-as name, if applicable;
(E) the physical location where non-tax-paid tobacco products are manufactured, received, or stored;
(F) the mailing address;
(G) the location where records are kept;
(H) the e-mail address, if available; and
(I) if the applicant or licensee elects to designate a contact person, the identity of the contact person including his or her legal name, telephone number, fax number, and e-mail address;
(3) the identity of the applicant's or licensee's owners, officers, partners, or members, and for each person identified, their:
(A) social security number, if a natural person;
(B) legal name;
(C) job title;
(D) residential address;
(E) phone number; and
(F) misdemeanor or felony convictions, if any, and a statement describing the circumstances of the conviction, including the offense, date of offense, date of conviction, case number, court jurisdiction, and any active terms of probation;
(4) the identity of persons who previously held an ownership interest in the applicant, and for each person identified:
(A) their legal name;
(B) the name of business at the time the interest was held;
(C) the address of business at the time the interest was held; and
(D) the last date of ownership in the applicant or licensee;
(5) if any person identified on the form previously owned, operated, or managed another legal entity selling, receiving, or purchasing tobacco products, the applicant or licensee shall include for each person identified:
(A) the person's legal name;
(B) the person's social security number;
(C) the person's residential address;
(D) the name of the legal entity; and
(E) the person's job title held at the legal entity;
(6) a description of the applicant's or licensee's operations, including:
(A) a designation of whether the applicant or licensee is a resident, nonresident, affiliated manufacturer, or integrated wholesaler;
(B) the percentage of operations that are associated with retail, distribution or wholesale, manufacturing, or other activities;
(C) the number of locations storing non-tax-paid tobacco products and the physical address for each location;
(D) the number of locations storing tax-paid tobacco products and the physical address for each location;
(E) the date when the applicant or licensee began or intends to begin to sell non-tax-paid tobacco products;
(F) a designation of whether a surety bond or letter of credit is included with the form;
(G) a designation of whether the applicant or licensee currently or intends to buy or sell tobacco products by Internet, telephone, catalog, or any other means that would qualify as a delivery sale;
(H) a designation of whether the applicant or licensee currently or intends to buy or sell roll-your own cigarette tobacco;
(I) a designation of whether the applicant or licensee currently or intends to import tobacco from out-of-country vendors;
(J) if the applicant or licensee is a nonresident distributor or wholesale dealer, designating whether the applicant or licensee is licensed in the applicant's or licensee's state of residence;
(K) a designation of whether the applicant or licensee currently or intends to purchase vapor products;
(L) a list of all states where the applicant or licensee holds a tobacco products license and the license number for each license;
(M) if the applicant or licensee is applying for a distributor's license:
(i) a list of all manufacturers that will sell to the applicant or licensee non-tax-paid cigarettes;
(ii) the address and phone number of all manufacturers that will sell to the applicant or licensee non-tax-paid cigarettes;
(iii) a letter from those manufacturers affirming the manufacturers intent to sell to the applicant or licensee non-tax-paid cigarettes; and
(iv) a list of all cigarette brands the applicant or licensee intends to sell;
(N) if the applicant or licensee is applying for wholesale dealer's or retail dealer's license:
(i) a list of all suppliers providing the applicant or licensee other tobacco products where the excise tax under G.S. 105-113.35 or G.S. 105-113.35A has not been paid;
(ii) the supplier's legal name;
(iii) the supplier's address;
(iv) the supplier's telephone number;
(v) for each supplier, the date the applicant or licensee first purchased other tobacco products from the supplier; and
(vi) the delivery method for each supplier not located in this State; and
(O) a list of roll-your-own cigarette tobacco brands that the applicant or licensee intends to sell, if any; and
(7) for the person authorized to legally bind the applicant or licensee, his or her:
(A) typed legal name;
(B) job title;
(C) signature;
(D) date of signature;
(E) telephone number;
(F) fax number;
(G) e-mail address; and
(H) affirmation that the form is accurate and complete.