Prevent All Cigarette Trafficking (PACT) Act Registration Form

OMB No. 1140-xxxx (xx/xx/xxxx)

U.S. Department of Justice
Bureau of Alcohol,Tobacco, Firearms and Explosives

Prevent All Cigarette Trafficking (PACT) Act
Registration Form (Continuation Sheet)

9. Address(es) of All Business Locations
a. Street Address

City

State

Zip Code

9b. Street Address

City

State

Zip Code

9c. Street Address

City

State

Zip Code

9d. Street Address

City

State

Zip Code

9e. Street Address

City

State

Zip Code

9f. Street Address

City

State

Zip Code

9g. Street Address

City

State

Zip Code

Telephone Number at All
Locations
10a.
10b. Telephone Number

10c. Telephone Number

10d. Telephone Number

10e. Telephone Number

10f. Telephone Number

10g. Telephone Number

11a. Name of Authorized Agent at Each Business Location (Last, first, middle) 12a. Internet Address for Business
Last
First
Middle
13a. E-Mail Address
11b.
Last

12b. Internet Address for Business
First

Middle
13b. E-Mail Address

11c.
Last

12c. Internet Address for Business
First

Middle
13c. E-Mail Address

11d.
Last

12d. Internet Address for Business
First

Middle
13d. E-Mail Address

11e.
Last

12e. Internet Address for Business
First

Middle
13e. E-Mail Address

11f.
Last

12f. Internet Address for Business
First

Middle
13f. E-Mail Address

11g.
Last

12g. Internet Address for Business
First

Middle
13g. E-Mail Address
ATF Form 5070.1A
Revised (
)

Paperwork Reduction Act Notice
The information required on this form is in accordance with the Paperwork Reduction Act of 1995. The purpose of the information is to register
delivery sellers of cigarettes and/or smokeless tobacco products with the Attorney General in order to legally continue to sell and/or advertise these
tobacco products. The information is mandatory as required by P.L. 111-154.
The estimated average burden associated with this collection is 1 hour per respondent or recordkeeper, depending on individual circumstances.
Comments about the accuracy of this burden estimate and suggestions for reducing it should be directed to Reports Management Officer, Document
Services, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number.