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

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

OMB No. 1140-0098 (xx/xx/xxxx)

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

Zip Code

State

8e. Name of Additional Place of Business

9e. Website Address for Additional Place of Business

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

City

Zip Code

State

8f. Name of Additional Place of Business

City

Zip Code

State

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8g. Name of Additional Place of Business

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)

13c. Address of Authorized Agent

R

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

14c. Telephone Number of Authorized Agent

D

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 ( )

Privacy Act Notice
1. Authority: Public Law No. 111-154, 15 U.S.C. § 376(a) (1) authorizes the collection of this information.
2. Purpose: ATF will use this information to create a database of all registered delivery sellers of tobacco products.
3. Routine Uses: The information will be used by ATF personnel and contractors, state and local government or other agents who need the information
to assist in activities related to criminal investigations or certain regulatory enforcement activities. Additionally, ATF may share the information upon
request with other law enforcement or other government agencies, as necessary to investigate and prosecute crimes, or pursuant to its published
Privacy Act system of records notice.
4. Disclosure: Information requested shall be disclosed in accordance with 15 U.S.C. § 376(a) (1) “[a]ny person who sells, transfers, or ships for profit
cigarettes or smokeless tobacco in interstate commerce, whereby such cigarettes or smokeless tobacco are shipped into a State, locality, or Indian
country of an Indian tribe taxing the sale or use of cigarettes or smokeless tobacco, or who advertises or offers cigarettes or smokeless tobacco for such
a sale, transfer, or shipment.”
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.

D

R

AF
T

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 (
)