Texas Cigarette, Cigar and Tobacco Products Report Forms-69-209 Ownership Supplement for Cigarette and Tobacco Products Permit(s)

1. PRINT FORM CLEAR FIELDS
69-209
(5-98)
TEXAS OWNERSHIP INFORMATION Comptroller Use Only
Job name - MISCAPP
FOR CIGARETTE, CIGAR, AND
TOBACCO PRODUCTS PERMIT(S) 00991
Reference no.
• PLEASE TYPE OR PRINT. • PLEASE ATTACH COPIES IF NECESSARY.
1. Legal name of owner 2. Taxpayer number
4. Social security or
3. Name federal employer identification number 5. Driver's license number State
6. Home address
OWNER
City State ZIP code 7. Phone (Area code and number)
8. Race 9. Sex 10. Date of birth (Month, day, year)
M F
11. Position (Check all applicable boxes)
01 - Sole owner 02 - Partner 03 - Director 04 - Officer 05 - Corporate Stockholder 06 - Record keeper
Percent of ownership or corporate stock held: _________________ %
12.
4. Social security or
3. Name federal employer identification number 5. Driver's license number State
6. Home address
OWNER
City State ZIP code 7. Phone (Area code and number)
8. Race 9. Sex 10. Date of birth (Month, day, year)
M F
11. Position (Check all applicable boxes)
01 - Sole owner 02 - Partner 03 - Director 04 - Officer 05 - Corporate Stockholder 06 - Record keeper
Percent of ownership or corporate stock held: _________________ %
12.
4. Social security or
3. Name federal employer identification number 5. Driver's license number State
6. Home address
OWNER
City State ZIP code 7. Phone (Area code and number)
8. Race 9. Sex 10. Date of birth (Month, day, year)
M F
11. Position (Check all applicable boxes)
01 - Sole owner 02 - Partner 03 - Director 04 - Officer 05 - Corporate Stockholder 06 - Record keeper
Percent of ownership or corporate stock held: _________________ %
12.
4. Social security or
3. Name federal employer identification number 5. Driver's license number State
6. Home address
OWNER
City State ZIP code 7. Phone (Area code and number)
8. Race 9. Sex 10. Date of birth (Month, day, year)
M F
11. Position (Check all applicable boxes)
01 - Sole owner 02 - Partner 03 - Director 04 - Officer 05 - Corporate Stockholder 06 - Record keeper
Percent of ownership or corporate stock held: _________________ %
12.