This document is a cigarette tax stamp order form from a wholesaler to Nevada's Department of Taxation. It requests specific quantities of cigarette tax stamps in different denominations (10s, 20s, 25s) to be delivered by a specified date and shipping method. It provides the wholesaler's billing and shipping information as well as the value of each type of stamp ordered, applicable discounts, and the total amount due for the purchase order.

1. Wholesaler:_______________________________________________________ License No:_______________________
Please send the following quantities of Nevada cigarette tax stamps on __________________________________________
(Date)
____________________________via our direct bill account number: __________________________________________
( ) United Parcel Service ( ) Airborne Express ( ) Federal Express ( ) Other ______________________________
All stamp orders will be sent overnight delivery unless otherwise specified. Billing invoice will be sent with the
stamp order.
Attention: _________________________________________
Name:_____________________________________________________________Phone:___________________________
Address:____________________________________________________________________________________________
City:__________________________________________ State:_____________________ Zip:__________________
Fuson Stamp (10’s) :
No. Sheets No. Stamps Value of Stamps
_________ _________ at $.40 each _____________
Less 0.5 percent discount _____________
Total amount for 10’s ______________
Fuson Stamp (20’s) :
No. Rolls / Sheets No. Stamps Value of Stamps
_________ _________ at $.80 each _____________
Less 0.5% or .005 discount _____________
Total amount for 20’s _____________
Fuson Stamp (25’s) :
No. Rolls No. Stamps Value of Stamps
_________ _________ at $ 1.00 each _____________
Less 0.5 percent discount _____________
Total amount for 25’s _____________
Tribal Stamps (No Charge) TOTAL AMOUNT
No. Rolls No. Stamps OF THIS PURCHASE
ORDER $________________
__________ __________
_______________________________________________________ ________________________________
Authorized Signature ( Signature on File) Date
Mail or fax to: Cigarette stamp order, Attn: Shirley Harvey, Department of Taxation, 1550 E. College Parkway
Carson City NV 89706. Fax No. 775-684-2020. Business No. 775-684-2129.