Form Gt 15 - Application For Nevada Motor Vehicle Fuel Dealers License

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APPLICATION FOR NEVADA MOTOR VEHICLE FUEL DEALERS LICENSE
APPLICATION IS HEREBY MADE FOR A LICENSE FOR THE IMPORTATION, REFINING AND/OR DISTRIBUTION OF PETROLEUM PRODUCTS IN THE
STATE OF NEVADA IN ACCORDANCE WITH NRS 365,373 AND 590.
$5.00
LICENSE FEE:
DATE:
SECURITY REQUIRED:
FEDERAL IDENTIFICATION NUMBER:
$
TYPE OF BUSINESS (OWNER, PARTNERSHIP, CORPORATION, OTHER):
TO BE DETERMINED BY THE DEPARTMENT
DEALER NAME (DBA):
CORPORATE NAME:
BUSINESS MAILING ADDRESS:
BUSINESS PHYSICAL LOCATION:
BUSINESS TELEPHONE NUMBER:
BUSINESS FACSIMILE NUMBER:
OWNER/PARTNER NAMES (OR) CORPORATE OFFICERS:
NAME:
TITLE:
SSN:
NAME:
TITLE:
SSN:
NAME:
TITLE:
SSN:
NAME:
TITLE:
SSN:
PERSON TO CONTACT REGARDING MONTHLY RETURNS:
NAME:
TITLE:
CONTACT TELEPHONE NUMBER:
CONTACT FACSIMILE NUMBER:
ESTIMATED MONTHLY GALLONAGE IMPORTED, REFINED AND/OR DISTRIBUTED IN THE STATE OF NEVADA:
GASOLINE/GASOHOL
LUBRICATING OIL
JET FUEL
HEATING OIL
AVIATION FUEL
BLENDING PRODUCTS
DIESEL (#1 AND #2)
ESTIMATED MONTHLY GALLONAGE EXPORTED FROM THE STATE OF NEVADA:
GASOLINE/GASOHOL
DIESEL (#1 AND #2)
AVIATION FUEL
HEATING OIL
THE UNDERSIGNED, BEING DULY SWORN, DEPOSES AND SAYS, UPON OATH, THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT:
AUTHORIZED SIGNATURE
SECURITY REQUIREMENTS: CONDITION AND AMOUNT (NRS 365.290)
BEFORE GRANTING ANY LICENSE, THE DEPARTMENT SHALL REQUIRE AN APPLICANT TO FILE WITH THE DEPARTMENT A SECURITY DULY
EXECUTED BY THE APPLICANT AS PRINCIPAL AND BY A CORPORATION QUALIFIED UNDER THE LAWS OF THIS STATE AS SURETY, PAYABLE TO
THE STATE OF NEVADA, CONDITIONED UPON FAITHFUL PERFORMANCE OF ALL THE REQUIREMENTS OF THESE CHAPTERS AND UPON THE
PUNCTUAL PAYMENT OF ALL EXCISE TAXES, FEES, PENALTIES, INTEREST AND OTHER OBLIGATIONS OF THE APPLICANT OF A DEALER.
THE TOTAL AMOUNT OF THE SECURITY REQUIRED OF ANY DEALER SHALL BE FIXED BY THE DEPARTMENT AT THREE TIMES THE ESTIMATED
MONTHLY TAX OR FEE, DETERMINED IN SUCH A MANNER AS THE DEPARTMENT DEEMS PROPER, AND MAY BE INCREASED OR DECREASED
ACCORDINGLY BY THE DEPARTMENT AT ANY TIME SUBJECT TO THE LIMITATIONS PRESCRIBED IN THESE CHAPTERS; BUT THE TOTAL
AMOUNT OF THE SECURITY OF ANY NEW DEALER MAY NOT BE LESS THAN $50,000. WHEN CASH OR A CERTIFICATE OF DEPOSIT OR
INVESTMENT CERTIFICATE IS USED, THE AMOUNT REQUIRED MUST BE PLEDGED THROUGH A BANK LOCATED WITHIN THE STATE OF NEVADA.
GT 15
23-Apr-97

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