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State, and who, to the satisfaction of the Department, furnish adequate security to insure payment of the tax, provided that any such permit shall extend only to cigarettes which such permittee manufacturer places in original packages that are contained inside a sealed transparent wrapper. Application for a permit shall be made to the Department, by electronic means, in a form prescribed by the Department. Such permits shall be issued without charge in such form as the Department may prescribe and shall not be transferable or assignable. (2) Each applicant for a permit under this subsection shall furnish to the Department in a form signed and verified by the applicant under penalty of perjury, in an electronic format established by the Department, the following: (A) a statement that the applicant will fully comply with the Tobacco Products Manufacturers' Escrow Enforcement Act of 2003; and (B) the following information: (i) the name and address of the applicant; (ii) the address of the location at which the applicant proposes to engage in business; and (iii) such other additional information as the Department may reasonably require by its rules. (3) The following are ineligible to receive a distributor's permit under this subsection: SB3019 Enrolled LRB104 20255 HLH 33706 b Public Act 104-0468