Form Gas 1301a - Application For Motor Fuel Transporter License - 1997
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1NORTH CAROLINA DEPARTMENT OF REVENUE
MFD
Form Gas 1301A
MOTOR FUELS TAX DIVISION
(6/97)
PO BOX 25000, RALEIGH NC 27640–0001
TELEPHONE (919) 733–3409 FAX (919) 733–8654
(Web)
APPLICATION FOR MOTOR FUEL TRANSPORTER LICENSE
***THERE IS NO CHARGE FOR THE LICENSE***
Instructions: Please carefully read the information provided. To obtain your license, complete the application and return to North
Carolina Department of Revenue, Motor Fuels Tax Division, PO Box 25000, Raleigh, North Carolina 27640–0001.
The following applicants are required by law to become registered with the Motor Fuels Tax Division:
A person that transports, by pipeline, marine vessel, railroad tank car or transport truck, motor fuel that is being imported into this
State or exported from this State must have a license and file a monthly return to report those imports or exports.
Motor carriers are required to become licensed as Motor Fuel Transporters if they:
1. Are Common or Contract Carriers: AND
2. Haul motor fuel interstate for other companies.
Intrastate motor fuel carriers and private carriers are not required to be licensed at this time.
1)
*Legal Name of Applicant
2)
Trade Name, If Different From Legal Name
3)
Business Type
Individual
General Partnership
Corporation (Domes-
Limited Liability Co
Limited Partnership
tic) Corporation (For-
eign)
4)
Primary Physical Business Location in North Carolina (Not PO
Box)
Street
City
County
5)
*Mailing Address (Street or PO Box)
State
Zip
6)
Country
7)
*Federal ID No., Social Security No. (Individual), or Social Insurance No. (Canada)
8)
Contact Person
9)
*Telephone Number
10)
*Fax Number
(
)
(
)
11)
*Complete for Partners or Corporate Officers (President, Vice President, Secretary and Treasurer)
NAME/TITLE
SOCIAL SECURITY NUMBER
TELEPHONE NUMBER
12)
*Complete The Following If Your Vehicles Are Involved In a Lease Agreement
TELEPHONE
Name and Address of Lessor
Name and Address of Lessee
13)
*Month, Day and Year Business Was Established
14)
*Indicate License for Motor Carrier Operations
North Carolina Highway Fuel
IFTA, Give Name of State
Use
15)
*Check Applicable Carrier Type(s)
16)
*Operations are?
Common
Contract
Private
Interstate
Intrastate (Only in NC)
17)
*IRP Base State
18)
*IRP Account Number
19)
*US DOT Number
Under penalties provided by law, I hereby affirm to the best of my knowledge and belief this application, including any accompanying schedules and
statements, is true and correct.
Date
Signature
Title
Application must be signed by owner of business, or if a partnership by partner, or if a corporation by an authorized agent or corporate officer.
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