Prevent All Cigarette Trafficking (PACT) Act Registration Form

OMB No. 1140-0098 (03/31/2014)

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

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

Section II - Additional Places of Business (Continued)
8d. Name of Additional Place of Business

9d. Website Address for Additional Place of Business

10. Address of Additional Place of Business
d. Street Address

City

State

8e. Name of Additional Place of Business

Zip Code

9e. Website Address for Additional Place of Business

10. Address of Additional Place of Business
e. Street Address

City

State

8f. Name of Additional Place of Business

Zip Code

City

State

8g. Name of Additional Place of Business

Zip Code

11f. Telephone Number at
Additional Location

9g. Website Address for Additional Place of Business

10. Address of Additional Place of Business
g. Street Address

11e. Telephone Number at
Additional Location

9f. Website Address for Additional Place of Business

10. Address of Additional Place of Business
f. Street Address

11d. Telephone Number at
Additional Location

City

State

Zip Code

11g. Telephone Number at
Additional Location

Section III - Agent Authorized to Accept Service (Continued)
12c. Name of Agent Authorized to Accept Service on Behalf of the Person (Person or Business Entity)
13c. Address of Authorized Agent

14c. Telephone Number of Authorized Agent

12d. Name of Agent Authorized to Accept Service on Behalf of the Person (Person or Business Entity)
13d. Address of Authorized Agent

14d. Telephone Number of Authorized Agent

12e. Name of Agent Authorized to Accept Service on Behalf of the Person (Person or Business Entity)
13e. Address of Authorized Agent

14e. Telephone Number of Authorized Agent

12f. Name of Agent Authorized to Accept Service on Behalf of the Person (Person or Business Entity)
13f. Address of Authorized Agent

14f. Telephone Number of Authorized Agent

12g. Name of Agent Authorized to Accept Service on Behalf of the Person (Person or Business Entity)
13g. Address of Authorized Agent

14g. Telephone Number of Authorized Agent

ATF Form 5070.1A
Revised April 2011

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.

ATF Form 5070.1A
Revised April 2011