Fillable Form Mft-2a - Application For Distributor License

14. Attach one copy of CERTIFIED FINANCIAL STATEMENTS for the last two fiscal years. Newly established companies should attach letter(s) from bank

or other financial institution providing credit references for new company.

15. List all suppliers of motor fuel. A copy of the contract from each supplier must be attached indicating type of product and where provided by supplier

________________________________________________________________________________________________________________________

16. Is applicant a licensed distributor, importer or exporter in another state or foreign country. Please indicate state, license number, and point of contact in

each state (to include name and telephone number). Additionally, please attach a copy of each license. If applicant is a foreign importer, include copy

of US Customs permit.______________________________________________________________________________________________________

17. Does applicant hold a Federal Form 637? If so, identify the issuing IRS District Office, provide copy of 637 certificate and also copies of applicant’s last

two quarterly Form 720 reports filed with the IRS. _________________________________________________________________________________

18. Does applicant hold any other New Jersey motor fuels license? If yes, explain _________________________________________________________

________________________________________________________________________________________________________________________

19. Has applicant ever had a New Jersey Motor Fuel License denied, suspended, canceled or revoked in New Jersey or any other jurisdiction? If yes,

explain:__________________________________________________________________________________________________________________

20. Does applicant have any outstanding liability or litigation? If yes, explain ______________________________________________________________

________________________________________________________________________________________________________________________

21. Indicate below the maximum number of gallons of motor fuels that you expect to import into this state and the maximum number of gallons of motor fuels

you expect to purchase within this state in any month.

IMPORTS ______________________ Gal.

NJ PURCHASES _______________________ Gal.

TOTAL HANDLE ___________________ Gal.

NOTE:

An “exchange” or “book transfer” of gasoline in this State is a purchase and or sale and must be reported by seller and purchaser. Reference:

N.J.S.A. 54:39-7.

22. Type of motor fuels to be handled and percentage of each.

__________________________ ________%

_____________________________ ________%

23. Describe in detail applicant’s planned activity and need for this license ________________________________________________________________

________________________________________________________________________________________________________________________

24. Indicate below by which type of carrier you expect to receive import motor fuels into this State.

¨ Tanker

¨ Pipeline (provide copy of agreement)

¨ Barge

¨ Tank Car

¨ Tank Truck

25. List below each manufacturing plant, wholesale plant (to include any leased storage) and retail station operated. Designate each by using “M” for

manufacturing, “W” for wholesale, “R” for retail and “L” for leased. (If more space is needed, attach rider)

Location

Class - M, W, R, L

Number of Tanks

Total Capacity Gallons

26. Is applicant registered for Petroleum Products Gross Receipts as required by the Act? .......................................... ¨ YES

¨ NO

27. Is applicant registered with the Division of Taxation for any other New Jersey State taxes? ................................... ¨ YES

¨ NO

28. 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

The information submitted will assist this office in the processing of your license request.

The Division of Taxation reserves the right to conduct a thorough investigation prior to issuing this license.

FOR DIVISION USE ONLY

License No. _______________________________________________

Investigation initiated __________________________________