1. (a) A distributor obtaining, renewing, or updating a license pursuant to G.S. 105-113.12 shall use Form B-A-2.
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.

3. (c) Form B-A-2 requires the following:

   1. (1) a description of the transactions requested, including:

      1. (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;
      2. (B) the applicant's or licensee's business structure, such as a sole proprietorship, partnership, corporation, limited liability company, limited liability partnership;
      3. (C) if requesting a new license or renewal of an existing license, the type of license requested;
      4. (D) the seven digit number assigned by the North Carolina Secretary of State, if applicable; and
      5. (E) the total payment due;

   2. (2) the applicant's or licensee's business information, including:

      1. (A) information required by 17 NCAC 01C .0322(b);
      2. (B) the legal name;
      3. (C) the date the business began operations;
      4. (D) the trade name or doing-business-as name, if applicable;
      5. (E) the physical location where non-tax-paid tobacco products are manufactured, received, or stored;
      6. (F) the mailing address;
      7. (G) the location where records are kept;
      8. (H) the e-mail address, if available; and
      9. (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. (3) the identity of the applicant's or licensee's owners, officers, partners, or members, and for each person identified, their:

      1. (A) social security number, if a natural person;
      2. (B) legal name;
      3. (C) job title;
      4. (D) residential address;
      5. (E) phone number; and
      6. (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. (4) the identity of persons who previously held an ownership interest in the applicant, and for each person identified:

      1. (A) their legal name;
      2. (B) the name of business at the time the interest was held;
      3. (C) the address of business at the time the interest was held; and
      4. (D) the last date of ownership in the applicant or licensee;

   5. (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:

      1. (A) the person's legal name;
      2. (B) the person's social security number;
      3. (C) the person's residential address;
      4. (D) the name of the legal entity; and
      5. (E) the person's job title held at the legal entity;

   6. (6) a description of the applicant's or licensee's operations, including:

      1. (A) a designation of whether the applicant or licensee is a resident, nonresident, affiliated manufacturer, or integrated wholesaler;
      2. (B) the percentage of operations that are associated with retail, distribution or wholesale, manufacturing, or other activities;
      3. (C) the number of locations storing non-tax-paid tobacco products and the physical address for each location;
      4. (D) the number of locations storing tax-paid tobacco products and the physical address for each location;
      5. (E) the date when the applicant or licensee began or intends to begin to sell non-tax-paid tobacco products;
      6. (F) a designation of whether a surety bond or letter of credit is included with the form;
      7. (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;
      8. (H) a designation of whether the applicant or licensee currently or intends to buy or sell roll-your own cigarette tobacco;
      9. (I) a designation of whether the applicant or licensee currently or intends to import tobacco from out-of-country vendors;
      10. (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;
      11. (K) a designation of whether the applicant or licensee currently or intends to purchase vapor products;
      12. (L) a list of all states where the applicant or licensee holds a tobacco products license and the license number for each license;

      13. (M) if the applicant or licensee is applying for a distributor's license:

          1. (i) a list of all manufacturers that will sell to the applicant or licensee non-tax-paid cigarettes;
          2. (ii) the address and phone number of all manufacturers that will sell to the applicant or licensee non-tax-paid cigarettes;
          3. (iii) a letter from those manufacturers affirming the manufacturers intent to sell to the applicant or licensee non-tax-paid cigarettes; and
          4. (iv) a list of all cigarette brands the applicant or licensee intends to sell;

      14. (N) if the applicant or licensee is applying for wholesale dealer's or retail dealer's license:

          1. (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;
          2. (ii) the supplier's legal name;
          3. (iii) the supplier's address;
          4. (iv) the supplier's telephone number;
          5. (v) for each supplier, the date the applicant or licensee first purchased other tobacco products from the supplier; and
          6. (vi) the delivery method for each supplier not located in this State; and
      15. (O) a list of roll-your-own cigarette tobacco brands that the applicant or licensee intends to sell, if any; and

   7. (7) for the person authorized to legally bind the applicant or licensee, his or her:

      1. (A) typed legal name;
      2. (B) job title;
      3. (C) signature;
      4. (D) date of signature;
      5. (E) telephone number;
      6. (F) fax number;
      7. (G) e-mail address; and
      8. (H) affirmation that the form is accurate and complete.

History Note: Authority G.S. 105‑113.11; 105‑113.12; 105-113.36; 105‑262;
Eff. January 1, 2021.