Form RPD-41218 Registration for Special Tax Programs

Business Name CIGARETTE OR TOBACCO REGISTRATION (505) 827 0762 Contact person Phone number GASOLINE OR SPECIAL FUEL REGISTRATION (505) 827 0773 Indicate type(s) of resources Liquor license no Type of liquor license LIQUOR REGISTRATION (505) 827 0768 Mailing Address P O Box 25123 Phone Number Place of purchase: q In State q Out of State PRINT NAME REGISTRATION FOR SPECIAL TAX PROGRAMS REV 02/2008 RPD 41218 Santa Fe NM 8750405123 SEVERANCE AND RESOURCES EXCISE TAX REGISTRATION (505) 827 1087 SIGNATURE Special Tax Programs and Services STATE OF NEW MEXICO TAXATION AND REVENUE DEPARTMENT TITLE TRD Identification Number Type of business: q Retail q Wholesale q Distributor q Manufacturer Type of business: q Retail q Wholesale q Distributor q Manufacturer q Vending Machine Type of business: q Supplier q Rack operator q Retailer Type of business: q Wholesale q Distributor q Rack Operator q Importer q Retailer Type of water system WATER PRODUCER REGISTRATION (505) 827 0763 Will business be engaged in processing natural resources? q YES q NO Will business be engaged in severing natural resources? q YES q NO Will business distribute special fuel? q YES q NO Will business sell cigarettes? q YES q NO Will business sell gasoline? q YES q NO Will business sell tobacco products? q YES q NO