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Application for license shall be made to the Department, by electronic means, in a form as furnished and prescribed by the Department. Each applicant for a license under this Section shall furnish to the Department in a on the form signed and verified by the applicant under penalty of perjury, in an electronic format established by the Department, the following information: (1) a statement that the applicant will fully comply with the Tobacco Products Manufacturers' Escrow Enforcement Act of 2003; and (2) the following information: (A) the (a) The name and address of the applicant; (B) the (b) The address of the location at which the applicant proposes to engage in business as a distributor of cigarettes in this State; and (C) such (c) Such other additional information as the Department may reasonably lawfully require by its rules and regulations. The annual license fee payable to the Department for the initial and each renewal distributor's license shall be $250. The purpose of the initial and renewal such annual license fee is to defray the cost, to the Department, of serializing cigarette tax stamps. Each applicant for license shall pay such fee to the Department at the time of submitting the his application for license to the Department. Through June 30, 2027, every Every applicant who is SB3019 Enrolled LRB104 20255 HLH 33706 b Public Act 104-0468