Motor Fuel Tax License Applicant Form - North Dakota
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2Motor Fuel Tax License Applicant - General Information
North Dakota Office of State Tax Commissioner
SFN 22911 (6-1999)
All information must be complete and accurate - Attach addendum if additional space is needed
Section 1: Business identity
Business name
Federal Employer Identification Number (FEIN)
Corporate or legal name
Mailing address (number and street, or post office box)
City
State
Zip Code
Telephone Number
Street address of business headquarters (if different from mailing address)
City
State
Zip Code
Location where business records are kept (if different from address of business headquarters)
City
State
Zip Code
Section 2: Type of ownership - Check one
Sole owner
Partnership
Limited Liability Partnership
Other
Corporation
Limited Partnership
Limited Liability Co.
Specify ______________
Section 3: Ownership information - Provide information for sole proprietorship, all partners, all
members of a limited partnership or a limited liability partnership, principal officers of a corporation,
or directors or governors of a limited liability company
Name (Last, first and middle initial)
Title
Social Security Number Date of Birth
Home address (Number and street)
City
State
Zip code
Name (Last, first and middle initial)
Title
Social Security Number Date of Birth
Home address (Number and street)
City
State
Zip code
Name (Last, first and middle initial)
Title
Social Security Number Date of Birth
Home address (Number and street)
City
State
Zip code
North Dakota law provides that no foreign corporation or foreign limited liability company may conduct business in this state or
obtain any license or permit required by this state until it has procured a certificate of authority from the secretary of state. North
Dakota law also provides that no foreign limited partnership or foreign limited liability partnership may conduct business in the state
until it has registered with the secretary of state. (Questions regarding certificates of authority and registrations should be directed to
the North Dakota Secretary of State at 701-328-4284.)
List the state in which your company is organized
Enter the ID number assigned to your business by the North Dakota Secretary of State or attach a copy of the Certificate of Authority
Section 4: Business status - Check one
New Business
Purchasing Existing Business
Change in Organizational Structure (sole ownership to corporation, etc.)
Change in Ownership
If you are purchasing an existing business, enter the name the business has been operating under
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