Form 72a300 (5-07) - Tax Registration Application For Motor Fuels License
ADVERTISEMENT
1
2
3
4TAX REGISTRATION APPLICATION FOR MOTOR FUELS LICENSE
72A300 (5-07)
Commonwealth of Kentucky
Print or Type All Answers
DEPARTMENT OF REVENUE
SECTION 1—GENERAL INFORMATION (Must be completed by all applicants.)
1. Check the license type for which this registration application is completed.
Gasoline Dealer's License (Complete Sections 2, 3, 4, 5 and 6.)
Terminal Owner-Operator (Complete Section 10.)
Special Fuels Dealer's License (Complete Sections 2, 3, 4 and 5.)
Liquefied Petroleum Gas Dealer's License (Complete Sections 2, 7 and 8.)
Motor Fuels Transporter's License (Complete Section 9.)
2. Check the reason for completing this application.
New Applicant
Reinstatement of License Number
Information Update
Other (specify reason)
3. Legal Business Name
4. Do you operate this business under any other name?
Yes
No
If yes, provide other name
5. Nature of Business (Provide an accurate description of this business's principal activity(ies) performed or product(s)
manufactured.)
6. Check the type of current ownership.
Individual
Partnership (Attach a copy of the partnership agreement.)
/
Corporation Date of Incorporation
State of Incorporation
(If state is other than Kentucky, see Item 15(B) below.)
Provide owner and/or corporate officer details below, or if corporations have joined in a partnership, attach a list of each
qualifying corporation and corresponding corporate officer details.
Last Name
First Name
M.I.
Title
Residence Address
Social Security Number
7. Does the applicant have any interest in any current or former motor fuels license or had any license or permit suspended,
cancelled or revoked?
Yes
No (If yes, attach a complete written explanation.)
8. Mailing Address and Telephone Number
(
)
–
P.O. Box or Number and Street/Highway
City
State
ZIP Code + 4
Telephone Number
(
)
–
Fax Number
Contact E-mail Address
9. Kentucky Business Location and Telephone Number (If more than one Kentucky location, attach list of all.)
(
)
–
Number and Street/Highway
City
County
State
ZIP Code + 4
Telephone Number
10. Address Where Records are Available for Audit and Telephone Number
(
)
–
Number and Street/Highway
City
State
ZIP Code + 4
Telephone Number
/
/
11. Give the date motor fuel activity began or will begin in Kentucky.
Month
Day
Year
12. Does or will your company have the capability to remit payments by electronic funds transfer?
Yes
No
Does or will your company have the capability to submit data via electronic filing programs?
Yes
No
13. Check and list major federal and state account numbers held by this business.
–
Federal Employer ID Number
Corporation Income Tax Number
KY Highway User (KYU) Number
Sales and Use Tax Number
KY Unemployment Insurance Number
Withholding Tax Number
14. List previous ownership data.
Name Under Which Business Operated
Owner Name and Current Address
(
)
–
Telephone Number
Motor Fuels Tax License Number(s)
15. Required Attachments:
(A) Applicants for new license and reinstatement must attach either an executed corporate surety bond on Revenue Form 72A301, a
line of credit letter, or provide documentation for an account with a financial institution maintaining a compensating balance.
(B) Nonresident corporations must attach a certified copy of their Certificate of Authorization to transact business in Kentucky issued
by the Kentucky Secretary of State. For information, contact the Secretary of State's office at (502) 564-3490.
(C) Attach a certified financial statement.
File only one application. For assistance, call (502) 564-3853, fax (502) 564-2906. Mail completed application and all attachments to: Motor
Fuels Tax Section, P.O. Box 1303, Station 63, Frankfort, KY 40602-1303. Overnight delivery 200 Fair Oaks Lane, Frankfort, KY 40620.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal