Form 74-100-99-1 - Petroleum Tax Registration Application - 1999
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2Form 74-100-99-1 Rev. 06/99
Mississippi
Petroleum Tax Registration Application
Return to:
State Tax Commission
Petroleum Tax Division
P. O. Box 1033
Jackson, MS 39215
Applicant must complete all spaces. Please mark N/A if not applicable.
1.
Legal Name:
2.
Business Name:
3.
Street Address:
City:
State
County
ZIP
4.
Mailing Address:
City:
State
ZIP
Ext.
Fax Number
5.
Phone Number:
Social Security Number
6.
Federal I. D. Number:
7. Please indicate the Permits needed by checking the appropriate boxes:
Petroleum Products Distributors Permits
Environmental Protection Fee
Distributor - Gasoline (automotive and aviation)
Refund Gasoline Dealer
Distributor - Special Fuel (diesel fuel, kerosene, fuel oil, jet fuel)
Marine Dealer - Diesel Fuel
Class A - Distributor Crankcase Lubricating Oil (motor oil)
Distributor - Compressed Gas (butane, propane)
Other Petroleum Tax Permits
Natural Gas, Compressed Gas,
Contractors Direct Pay Permit
Locomotive Fuel User's Permit
for Special Fuel
Refund Gasoline Users
Retail Dealer - Dyed Diesel Fuel
8.
Is this a new business?
Yes
No
If not, who was the previous operator?
What was the business
Partnership -
9.
Type of Ownership:
Corporation
Sole Proprietor
Other:
If Corporation or Partnership, list names of officers, directors, managing partners, or members who have any responsibility for
10.
fiscal management of the organization. (If space provided is insufficient, please attach schedule.)
Address
Social Security
%
Name
Title
Number
Owned
11.
Corporation organized under the laws of State of
Year
12.
Date admitted or authorized to do business in Mississippi.
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