Form Mft-1a - Application For Seller - User'S License - 2000
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1
2MFT-1A
STATE OF NEW JERSEY
(02-00, R-6)
DIVISION OF TAXATION
Application Required by
MOTOR FUEL TAX
NJ Motor Fuel Tax Law
PO BOX 189
Trenton, New Jersey 08695-0189
APPLICATION FOR SELLER - USER’S LICENSE
Complete this application to request a Seller-User’s License which is needed whenever “special fuels” (diesel, kerosene, LP gas, #2 fuel oil, home
heating oil, etc.) are purchased or sold within the State of New Jersey. This license is for a period of three (3) years. A payment of the fee of $150.00
must accompany this application. There is no fee to holders of New Jersey Motor Fuel Retail Dealer, Wholesale Dealer or Distributor Licenses. In
general, every Seller-User’s license is subject to the filing of a bond in such form and amount as provided by law. Make check or money order payable
to: STATE OF NEW JERSEY-MFT.
1. FID #
-
OR Soc. Sec. # of Owner
-
-
2. Name ________________________________________________________________________________________________________________
(IF INCORPORATED - give Corp. Name; IF NOT - give Last name, First Name, MI of Owner(s))
3. Trade Name ___________________________________________________________________________________________________________
5. Mailing Name and Address - (if different from business address)
4. Business Location:
Street _____________________________________________________
Name________________________________________________
City_________________________________________ State
Street________________________________________________
-
Zip Code
City____________________________________ State
(Give 9-digit Zip)
-
Zip Code
¨
¨
4a. Business Location:
Owned
Leased
(Give 9-digit Zip)
4b. If leased please provide name and address of owner:
Name ___________________________________________________________________________________________________________________
Address _________________________________________________________________________________________________________________
6. Beginning Date for this business in New Jersey
__________ / __________ / __________
Month
Day
Year
7. Type of Ownership (check one):
¨
¨
¨
¨
¨
NJ Corporation
Sole Proprietor
Partnership
Out-of-State Corporation
Limited Partnership
¨
Other - explain _________________________________________________________________________________________________________
8. Telephone Numbers: Contact Person ______________________________________________
Title _____________________________________
Daytime: (
) _________ - _________________Ext___________
Evening: (
) _________ - _________________Ext__________
9. IF A CORPORATION, complete the following:
Date of Incorp. __________ / __________ / __________
State of Incorp.
Month
Day
Year
10. Provide the following information for ALL owners, partners or responsible corporate officers. (If more space is needed, attach rider).
%
NAME
SOCIAL SECURITY NUMBER
HOME ADDRESS
(Last Name, First, M.I.)
OWNED
TITLE
(Street, City, Zip)
NOTE: On a separate sheet of paper provide the name of stockholders owing 10% or more of the outstanding shares of stock in the corporation.
11. List parent company, wholly owned subsidiaries, and/or any affiliates_________________________________________________________________
________________________________________________________________________________________________________________________
12. Give name, title, and telephone number of person charged with the duty of filing motor fuels tax reports and location where reports are prepared and
records kept ______________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
13. Give name, title and address of agent in New Jersey or registered New Jersey agent on whom service may be made (must be documented by letter from
agent) ___________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
NOTE: Question 13 must be completed by out-of-state businesses
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