F.o.t. Application 2 Fuel Oil Tax Act Form

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F.O.T. APPLICATION 2

FUEL OIL TAX ACT

Section 12 (2) Fuel Oil Vendor Licence Information

1. Name of Applicant (legal name of business organization, proprietor or partners)

_____________________________________________________________________________________________

2. Registered Trade Name — if applicable (Doing Business As)

_____________________________________________________________________________________________

3a. Business Location ___________________________________________________________________________

3b. Mailing Address _____________________________________________________________________________

4. Accounting Office Address ____________________________________________________________________

5. Type of Ownership:

Corporation

Registered Association

Partnership

Individual Proprietor

6. Owners: If Corporation, names of officers; if Partnership, names of partners.

Title

Name

Address

_________________________

_______________________

________________________________________

_________________________

_______________________

________________________________________

_________________________

_______________________

________________________________________

I, _____________________________________________, ______________________________________________

(Name - Please Print)

(Title - Please Print)

as a duly authorized officer of ______________________________________________________________________

(Company Name - Please Print)

hereby CERTIFY that the information contained in this application is correct to the best of my knowledge and belief and

hereby make application as required under the Fuel Oil Tax Act and undertake to comply with the provisions of this Act

and the Regulations thereunder.

______________________________________________

_______________________________

Date

Signature

_______________________________

__________________________________________________

Date

Signature

(If the applicant is a corporation, the application shall be under SEAL of the Corporation. If a partnership, signatures of all partners are required.)

Prepare in duplicate for EACH LOCATION requiring a licence pursuant to the Act. Return original to the:

Deputy Head

Department of Finance

Government of Yukon

PO Box 2703

Phone: (867) 667-5345

Whitehorse, Yukon Y1A 2C6

Fax:

(867) 456-6709

YG(602EQ)F2 04/2013