The following statutes affect this form: ss. 77.61 (11) and 134.65, Wis. stats. STATE OF WISCONSIN
Town of ________
________ County
________ ________, of the Town of ________, ________ County, Wisconsin, having done all of the following:
1. Filed with the undersigned town clerk a complete application for a tobacco products retailer license.
2. Paid the license fee of $_____ [amount may not be less than $5 nor more than $100] to the treasurer of the town.
3. Submitted the proof required under s. 77.61 (11), Wis. stats. And the application having been granted by the town board on __________, _____, 20__;
A tobacco products retailer license is granted to __________ __________ to sell cigarettes, electronic vaping devices, and tobacco products under s. 134.65, Wis. stats., on the following premises in the town: [describe premises]. The license will expire on June 30, 20__, unless sooner revoked.*
Dated this ______ day of ________, 20__.
[Signatures of town board]
Attest: [Signature of town clerk]
*Note: Under s. 134.65 (2) (b), Wis. stats., a town may opt to issue licenses that expire one year from issuance rather than expiring on June 30 of each year.
