Item number 10 must be completed by out-of-state businesses.
10. 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) _____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
11. If applicant operates retail dealer service stations in applicant’s name in New Jersey or sells on consignment or commission sales basis to any
person, complete the following:
(a) List location and storage capacity of each company-owned service station. (attach separate rider)
(b) List names and locations of the dealers to whom applicant delivers on consignment or commission basis. (attach separate rider)
12. Operation in New Jersey (gallons):
(a) Total estimated monthly sales _______________________________ uses __________________________________________
(b) Number of gallons of gasoline sold by month in New Jersey to different types of customers.
Number of Different
Monthly Gallons
Customers
(Sales and Uses)
1. NJ Retail Dealers (not including company-operated) . . . . . .
___________________________ ___________________________
2. Fleet Operators (at least five vehicles used in business) . . . .
___________________________ ___________________________
3. Large customers (must purchase 2,000 gallons or more
annually and who have at least 300 gallon storage capacity)
___________________________ ___________________________
4. Farmers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
___________________________ ___________________________
5. Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
___________________________ ___________________________
6. Total Disposals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
___________________________ ___________________________
13. Source of Gasoline
Name of Supplier
Location
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
14. Does applicant hold a Federal Form 637? If so, identify the issuing IRS District Office, provide copy of 637 certificate and copies of your last two
quarterly Form 720 reports filed with the IRS.
_______________________________________________________________________________________________________________________
15. Does applicant hold any other New Jersey motor fuels license? If yes, explain _______________________________________________________
_______________________________________________________________________________________________________________________
16. Has applicant or any related party ever had a Motor Fuel License denied, suspended, cancelled or revoked in New Jersey or any other state? If yes,
explain _________________________________________________________________________________________________________________
17. Does applicant have any outstanding liability or litigation? If yes, explain ___________________________________________________________
_______________________________________________________________________________________________________________________
18. Describe in detail applicant’s planned activity and need for this license. _____________________________________________________________
_______________________________________________________________________________________________________________________
¨ YES
¨ NO
19. Is applicant registered for Petroleum Products Gross Receipts Tax as required by the Act? . . . . . . . . . . . . . . . .
20. The undersigned applicant states (under penalty of perjury) that all the information contained in this application is true and accurate in every
particular.
____________________________________________________
_________________________________________________________
Name of Applicant
Signature of Owner, Partner or Officer
_________________________________________________________
Title
Date
All information must be provided before the application can be processed.
The information submitted will assist this office in the processing of your request.
The Division of Taxation reserves the right to conduct a thorough investigation prior to renewing this license.
Return completed application and $450 fee to: MOTOR FUEL TAX, PO Box 189, Trenton, NJ 08695-0189
FOR DIVISION USE ONLY
License No. ______________________________________________
Investigation Initiated ____________________________________________
Effective Date_____________________________________________
Investigation Completed __________________________________________
Approved ________________________________________________
Recommendations: ___________________________________________________________________________________________________________
MFT-5R