Form Mf-627 - Cancellation Of License - Indiana Department Of Revenue - 2010
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1MF-627
State Form 49115
Indiana Department of Revenue
(R3 / 10-10)
Cancellation of License
Company Name:
DBA Name:
Address:
City:
State:
Zip Code:
Please provide a license number for all license types you wish to cancel:
1. Effective Date of Cancellation: ______________________________________________________________________________
2. Gasoline Distributor’s License Number: _______________________________________________________________________
3. Oil Inspection Distributor’s License Number: ___________________________________________________________________
4. Aviation Fuel Dealer’s Number: _____________________________________________________________________________
5. Marina Fuel Dealer’s Number: ______________________________________________________________________________
6. Special Fuel Importer’s License Number: _____________________________________________________________________
7. Special Fuel Transporter’s License Number: ___________________________________________________________________
8. Special Fuel Exporter’s License Number: _____________________________________________________________________
9. Special Fuel Supplier’s License Number: _____________________________________________________________________
10. Special Fuel Permissive Supplier’s License Number: ____________________________________________________________
11. Special Fuel Terminal Operator’s License Number: _____________________________________________________________
12. Special Fuel Blender’s License Number: ______________________________________________________________________
13. Special Fuel Dyed User’s License Number: ___________________________________________________________________
14. Special Fuel Eligible Purchaser’s License Number: _____________________________________________________________
15. Petroleum Severance License Number: ______________________________________________________________________
16. Indiana Prepaid Number: _________________________________________________________________________________
17. Gasohol Blender License: _________________________________________________________________________________
Signature:
Typed or Printed Name:
Title:
TID:
Date Signed:
Telephone Number:
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Parent category: Legal