Form Mf 100a - Fuel Tax License Application Page 2
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4Ownership Information
All applicants must complete this section. Failure to provide information below is grounds for denial of licensing. List names of all owners,
partners, or principal officers. Home addresses and phone numbers must be supplied along with each individual’s Social Security Number.
Attach an additional sheet if necessary.
Name
Title
Personal address
City
State
Zip
Social Security Number
Home Telephone
Name
Title
Personal address
City
State
Zip
Social Security Number
Home Telephone
Name
Title
Personal address
City
State
Zip
Social Security Number
Home Telephone
Name
Title
Personal address
City
State
Zip
Social Security Number
Home Telephone
South Dakota Tax License History
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Do you have any current or canceled tax licenses issued by the South Dakota Department of Revenue & Regulation?
Yes
No
If yes, please list below. (“Type” includes sales, use, contractors’ excise, motor fuel, liquor, cigarette, IFTA, IRP, etc.)
Type
License Number
Date of Operation
Type
License Number
Date of Operation
Type
License Number
Date of Operation
Fuel Types
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Indicate the fuel product that you currently handle or plan on handling:
Undyed Diesel
Dyed Diesel
Jet Fuel
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!
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!
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Avgas
Gasoline
Gasohol
100% Ethyl Alcohol
Methyl Alcohol
Liquid Petroleum Gas(LPG)
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!
Compressed Natural Gas (CNG)
Other - Please List:
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Parent category: Financial