* Required to submit
Has any of the proprietors listed above been determined to have violated any state or federal tobacco laws in the past 24 months? If so, list all violations and dates of each violation:
I certify that the information provided is true and accurate. I understand that any incorrect information may result in the suspension or revocation of the tobacco retailer permit. I also understand that the health department may recommend to the business licensing entity that the business license be suspended or revoked. Any such action will be reported to the Utah State Tax Commission. By clicking this box, I am signing this application and my signature binds all proprietors for the business listed on this application to the above agreements.