Form Ibr-3 - Idaho Fuel Distributor License Application - 2010 Page 2
ADVERTISEMENT
1
2
3
4IBR-3
EFO00204-2
06-17-2010
22. List the names and locations of all retail facilities, card/keylocks, bulk plants, and other fuel sales/storage facilities operated,
or proposed to be operated, by the applicant. Attach separate sheet for additional locations, if necessary.
Name
Location
23. Estimate the number of gallons of fuel you will sell in Idaho and the gallons of fuel you will export each month:
Gallons sold in Idaho
Gallons exported from Idaho
_______________ Gasoline
_______________ Gasoline
_______________ Diesel
_______________ Diesel
_______________ Other (type):__________________________
_______________ Other (type):____________________________
24. Has the applicant, its owner(s), partners, principal stockholders, or corporate officers:
a. Been convicted of fraud, tax evasion, or a violation of the laws governing the reporting
and payment of fees or taxes for petroleum products, in the past five (5) years? ....
Yes
No
If yes, attach explanation.
Been convicted of any felony or been granted a withheld judgment following an
b.
adjudication of guilt of a felony, in the past five (5) years? ........................................
Yes
No
If yes, attach explanation.
c. Formerly held a fuel tax license or permit in any jurisdiction which was revoked
for cause, in the past five (5) years? ..........................................................................
Yes
No
If yes, attach explanation.
d. Have any fuel tax liabilities that are past due with any jurisdiction? ..........................
Yes
No
If yes, attach explanation;
list jurisdiction(s), the
amount, and reason for
the liability.
25. If you are granted this license, do you expect to:
a. Export fuel from Idaho? ....................
Yes
No If yes, to which jurisdictions?___________________________________
b. Import fuel into Idaho? ......................
Yes
No If yes, from which jurisdictions?_________________________________
c. Take ownership of the fuel at an Idaho terminal? ......................................................
Yes
No
d. Sell fuel to other Idaho licensed distributors? ............................................................
Yes
No
e. Sell fuel to nonlicensed resellers within Idaho? .........................................................
Yes
No
f.
Deal in dyed petroleum products? .............................................................................
Yes
No
g. Make deliveries of home heating fuel? ......................................................................
Yes
No
h. Blend gasoline or diesel fuel with ethanol or other alcohol? ......................................
Yes
No
i.
Blend gasoline or diesel fuel with other petroleum products? ....................................
Yes
No
j.
Blend diesel fuel with agricultural products or the waste of such products? ..............
Yes
No
CERTIFICATION: I certify that I am authorized as an owner, partner, corporate officer or representative to sign this document and that the statements
made are correct to the best of my knowledge. (This form must also be signed by the spouse of a sole proprietor.)
Signature __________________________________ Date_______________
Signature __________________________________ Date_______________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial