License number assigned
P.O. Box 530
Columbus, OH 43216-0530
Application for License as a Retail Motor Fuel Dealer
Pursuant to Ohio Revised Code section (R.C.) 5735.02, I/we hereby apply for a motor fuel dealer’s license. For sole owner,
print individual’s name, address, owner’s SSN and FEIN of the business. For a partnership, print full name, address, and
SSN of all partners and the partnership’s FEIN. For an LLC or LLP, print the full name, address and SSN of all members. For
a corporation, print the corporate name, corporation charter number issued by the Secretary of State authorizing business
in Ohio and the corporation’s FEIN. Use a separate piece of paper if necessary.
Under penalties of prosecution, no person shall make a false
or fraudulent statement on this application.
1. Name of applicant
(If you are a corporation, DO NOT use your name, use the corporation name.)
Ohio charter number
2. Trade name if other than above
3. Check whether applicant operates as:
4. If a corporation, date of qualiﬁ cation
List name, address and SSN of all corporate ofﬁ cers and directors
5. If a corporation, state name and address of statutory agent
6. If partnership, list name, address and SSN of all partners. If LLC or LLP, list name, address and SSN of all members.
7. Location detail. List physical address of every retail location in Ohio – P.O. boxes not acceptable.
Also, list the estimated
monthly gallonage disbursement for each location listed (use a separate sheet of paper, if necessary).
8. Mailing address (if other than that shown on line 7)
9. Is your company owned or controlled by any other person or corporation?
No If yes, give name, address
and FEIN or SSN or the other person/corporation.
10. Do you maintain accurate and detailed records of all bulk motor fuel receipts?
No If yes, how long are