Application For Authorization To Sell Colored Fuel Form
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1
2
3Ministry of
Mailing Address:
APPLICATION FOR AUTHORIZATION
Provincial Revenue
PO Box 9442 Stn Prov Govt
TO SELL COLOURED FUEL
Consumer Taxation Branch
Victoria BC V8W 9V4
Motor Fuel Tax Act
Information is also available on the Internet:
Instructions:
Freedom of Information and Protection of Privacy Act (FIPPA)
•
The business or person who owns the coloured fuel must complete this
The personal information requested is collected under the
authority of and used for the purpose of administering the Motor
application. If your fuel supplier owns the coloured fuel at one of your
Fuel Tax Act . Questions about how the FIPPA applies to this
business locations, that supplier must submit an application for that location.
personal information can be directed to the general inquiry line
• If you need help in determining eligible uses of coloured fuel, please
at 604 660-4524 in Vancouver, or toll-free at 1 877 388-4440
contact Taxpayer Services in Vancouver at 604 660-4524 or toll-free
elsewhere in Canada, or in writing to Revenue Programs
elsewhere in Canada at 1 877 388-4440, or by email:
Division, Suite 800 - 360 West Georgia Street, Vancouver BC
V6B 6B2.
CTBTaxQuestions@gems9.gov.bc.ca.
PART 1 – Contact Information
1
LEGAL NAME OF APPLICANT
INCORPORATION NUMBER
BUSINESS NUMBER
2
DOING BUSINESS AS
3
MAILING ADDRESS
CITY
PROVINCE
POSTAL CODE
4
CONTACT PERSON
TITLE
PHONE NO.
FAX NO.
EMAIL ADDRESS
(
)
(
)
PART 2 – Location/Pump Information
Complete the following for each location that will be selling coloured fuel. (Please copy for each additional location as required.)
5
Physical location
CITY
STREET ADDRESS
PROVINCE
POSTAL CODE
6
Contact name and phone number – if different than #4 above.
NAME
PHONE NUMBER
(
)
7
How much fuel do you colour at this location?
COLOURED GASOLINE
COLOURED DIESEL
Provide the approximate number of litres of
gasoline and diesel coloured on an annual basis.
8
How much coloured fuel do you purchase in BC for this location?
Provide the approximate number of litres of
COLOURED GASOLINE
COLOURED DIESEL
coloured gasoline and coloured diesel purchased
annually.
9
How much coloured fuel do you import into BC for this location?
11
What is the approximate number of litres of coloured fuel sold
annually by each of the following methods for this location?
Provide the approximate number of litres of coloured gasoline
and coloured diesel imported annually.
Bulk Delivery (to a customer’s location)
COLOURED GASOLINE
COLOURED DIESEL
Cardlock/Keylock (in-house charge sales)
Self-Serve Pump (cash, debit or credit card)
10
How many pumps dispense coloured fuel at this location?
Full-Service Pump (cash, debit or credit card)
NUMBER OF PUMPS
TOTAL ANNUAL VOLUME
PART 3 – Certification by Applicant
12
The Applicant agrees:
• they have title (i.e., ownership) to all coloured fuel sold;
• the information contained in the application package and the current status of a business’s authorization plus any subsequent
reports may be shared with other British Columbia government agencies, with other governments and their agencies, and with
suppliers of coloured fuel where the disclosure relates to the administering and enforcing of taxation legislation. This includes
a public Web site listing all business names and locations authorized to sell coloured fuel and those authorizations that are
suspended or cancelled; and
• the statements made in this application are true and complete to the best of the Applicant’s knowledge.
Please type or print clearly
SIGNATURE OF AN AUTHORIZED PERSON
NAME AND TITLE –
DATE SIGNED
YYYY / MM / DD
X
FIN 461/WEB Rev. 2004 / 7 / 8
Clear Form
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