Form 72a300 (5-07) - Tax Registration Application For Motor Fuels License Page 3
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4SECTION 5—PRODUCTION INFORMATION
Does or will the applicant regularly engage in the business of refining, producing, distilling, manufacturing, blending, or compounding fuel in
Kentucky?
Yes (Check block(s) that apply.)
Gasoline
Special Fuels
Street or Highway and City Location
KY
No
SECTION 6—GASOLINE SALES INFORMATION
List gallons of gasoline sold in Kentucky during the past consecutive 12-month period on which your company paid the state gasoline
excise tax to your supplier(s).
Month/Year
Gallons Sold
Month/Year
Gallons Sold
1.
7.
2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
SECTION 7—LIQUEFIED PETROLEUM GAS DISTRIBUTION INFORMATION
1. Does or will the applicant distribute liquefied petroleum gas in Kentucky for use in motor vehicles upon the public highways?
Yes
No (If yes, complete this section.)
2. How is the fuel transported?
Own Equipment (Attach a list of all truck vehicle identification numbers.)
For Hire Carrier (Attach a list of all transporters' names and addresses.)
3. List supplier(s) below.
Company Name
Address
City Origin of Product
KY
KY
KY
4. List customer(s) below.
Company Name
Address
City and State Destination
SECTION 8—LIQUEFIED PETROLEUM GAS USE INFORMATION
Does or will the applicant operate any motor vehicles which use liquefied petroleum gas for the propulsion of that motor vehicle on the
public highways?
Yes
No (If yes, complete this section. Attach additional list if necessary.)
Vehicle Identification
License Plate
Year, Make and Model
Kentucky LP Gas Exemption
Number
Number
of Vehicle
Permit Number
SECTION 9—TRANSPORT INFORMATION
Does or will the applicant engage in the business of transporting gasoline or special fuels into Kentucky or between points within
Kentucky?
Yes
No (If yes, complete this section. Attach additional list if necessary.)
Vehicle Identification Number
License Plate Number
Year, Make and Model of Vehicle
➤ IMPORTANT: APPLICATION MUST BE SIGNED BELOW.
The information contained in this application is hereby certified to be correct to the best knowledge and belief of the undersigned who is
authorized to sign this application. Signature of owner or partners is required. If a corporation, an officer must sign.
Signature
Print Name
Title
Date
Signature
Print Name
Title
Date
Signature
Print Name
Title
Date
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