(a) The name, address, and telephone number of each proprietor of the business seeking a permit.

(b) The business name, address, and telephone number of the single, fixed location for which a permit is sought.

(c) A single name and mailing address authorized by each proprietor to receive all communications and notices (hereinafter, “authorized agent”) required by, authorized by, or convenient to the enforcement of this article. If an authorized agent is not supplied, each proprietor shall be understood to consent to the provision of notice at the business address specified in subsection (1)(b) of this section.

(d) Proof that the location for which a tobacco retailer permit is sought has been issued a valid state tobacco retailer’s license by the California Board of Equalization.

(e) Whether any proprietor or any agent of the proprietor has been issued a permit pursuant to this article that is or was at any time suspended or revoked, and, if so, the dates of the suspension period or the date of revocation.

(f) Whether any proprietor or any agent of the proprietor has admitted violating or has been determined to have violated any provision of this article or any state or federal tobacco-related law, and, if so, the dates of all such violations within the preceding five years.

(g) Such other information as the department deems necessary for the administration or enforcement of this article as specified on the application form required by this section.