Form Mft-4 R - Application For Renewal Of An Importer'S License Page 2

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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. Attach one copy each of CERTIFIED FINANCIAL STATEMENTS for the last two fiscal years.

12. 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

________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

13. 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 (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. _________________________________________________________________________________________

_______________________________________________________________________________________________________________________

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

two quarterly Form720 reports filed with the IRS. ___________________________________________________________________________

15. Does applicant hold any other New Jersey Motor Fuel 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 jurisdiction?

If yes, explain ___________________________________________________________________________________________________________

17. Does applicant have any outstanding liability or litigation? If yes, explain ___________________________________________________________

_______________________________________________________________________________________________________________________

18. 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

fuel 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.

19. Describe in detail applicant’s planned activity and need for this license. _____________________________________________________________

_______________________________________________________________________________________________________________________

20. 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

21. List below each manufacturing,plant, wholesale plant (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)

Class

Number

Total Capacity

Location

M, W, R, L

of Tank

Gallons

22. Qualification for an importer license may be predicated upon applicant meeting the test of an importer. An importer is a person who brings gasoline

into this state in his own vehicles, or who hires a common carrier to transport the product, and who has full ownership, possession, custody, control

and direction of the fuel while in transit into this State. Title to gasoline cannot change while in transit in a pipeline.

a. Will applicant’s imports qualify as defined above? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ! YES

! NO

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

! NO

24. 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