Form 3712 - Motor Fuel Tax License Application
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Michigan Department of Treasury
3712 (Rev. 10-03)
This form is issued under authority of P.A. 403 of 2000,
as amended. Filing is mandatory.
Motor Fuel Tax License Application
Failure to provide all information will delay
the processing of your application.
PART 1: IDENTIFYING INFORMATION
4
If a corporation or LLC, State of Incorporation
1. Type of Ownership:
Other:_____________
Individual
Partnership
Date Incorporated
Domestic Corporation
Foreign Corporation
Trust/Estate
LLC (Limited Liability Corporation)
Corporate or LLC Number (if applicable)
S. Corporation
LLP (Limited Liability Partnership)
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2. Legal Name
3. Federal Employer Identification Number (FEIN), TR, or ME Number
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5. Business Telephone Number
6. Business Fax Number
4. Trade Name (DBA)
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7. Legal Address (Street, RR#, P.O. Box, City, State, ZIP)
8. Mailing Address (Street, RR#, P.O. Box, City, State, ZIP)
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10. Licensing Contact
11. Tax Preparer Contact
9. Physical Location of Business (Not P.O. Box)
(name, telephone no., fax no., email)
(name, telephone no., fax no., email)
PART 2: OWNERSHIP INFORMATION
Lines 12-14 must be completed for each corporate officer, principal, partner or owner. Attach additional sheet(s) if necessary.
A.
B.
C.
D.
E.
Title
Full Name
Residence Address
Residence
Social
(first, middle, last)
(Street or RR#, city, state, Zip)
Telephone Number
Security Number
12.
13.
14.
15. Foreign Corporations: Name and Complete Address of Resident Agent
FEIN of Resident Agent
Telephone Number of Resident Agent
16. Has the corporation, LLC, LLP, partnership, or any officers, members,
17. Has the corporation, LLC, LLP, partnership, or any officers, members,
controlling shareholders of the corporation or owners of the business
controlling shareholders of the corporation or owners of the business had
been convicted of any felony or misdemeanor involving motor fuel or any
a motor fuel license revoked or refused for issuance or renewal in the
tax issues?
State of Michigan or another state or foreign jurisdiction?
Yes
No
Yes
No
If yes, explain:
If yes, explain:
18a. Has the corporation, LLC, LLP, partnership, or any officers,
18b. Has the corporation, LLC, LLP, partnership, or any officers,
members, controlling shareholders of the corporation or owners of the
members, controlling shareholders of the corporation or owners of the
business been licensed in another name in Michigan?
business been licensed in another state?
Yes
No
Yes
No
Name previously licensed under:______________________________
State previously licensed under:______________________________
Account Number (FEIN, TR, ME):_____________________________
19. Date Motor Fuel Operations began in Michigan
20. Anticipated effective date of license(s) (MM/DD/YYYY)
21. This form must be signed by the owner, two partners or two corporate officers responsible for filing returns and making tax payments.
I declare under penalty of perjury, that I have examined this application, including accompanying schedules and statements, and to the best of my
knowledge, it is true and complete.
Signature
Printed Name
Title
Date
Signature
Printed Name
Title
Date
22. Fee
$0
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