Form Mf-100 - Application For Fuel License - 2003
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APPLICATION FOR FUEL LICENSE
Send application to:
Department Use Only
Post Office Box 8902
(Failure to provide all information
requested will delay the processing
Wisconsin Department of Revenue
Transporter #
of your application)
Madison, WI 53708-8902
(608) 261-6435
Date
TTY (608) 267-1049
FAX (608) 267-1030
Approved By
SECTION 1 – All Applicants Must Complete Section 1
Please print or type information below
TYPE OF LICENSE - Check license(s) you are applying for:
Motor Vehicle Fuel Tax:
Other Fuel Types:
Supplier (position holder at a
Petroleum products shipper (required to remit the petroleum inspection
pipeline terminal location)
fee but not needed if licensed as a motor vehicle fuel supplier)
Restricted Supplier
Alternate fuel dealer/user (for example: LPG, CNG)
Import (from out-of-state bulk storage)
General aviation fuel dealer/user (for example: jet turbine fuel, AVGAS)
Export (from Wis. bulk storage)
Fuel transporter registration
1. True Name (corporation, limited liability company, partnership or individual)
Federal Employer ID No.
Telephone No.
(
)
2. Trade or Business Name
Social Security No.
(required
Business Telephone
if sole proprietor)
(
)
3. Business Address (street/route - do not use PO Box)
City or Post Office
State
Zip Code
4. Mailing Address (if different from business address)
City or Post Office
State
Zip Code
5. Business Located In:
City
In the Wisconsin county of:
(check one and indicate county)
Village of: ______________________________
_______________________________
Town
6. Organization (check one)
Governmental Unit (check appropriate box below)
5b
1
Sole Proprietor
Federal
County
2
Partnership
Wisconsin State Agency
Local
3
Wisconsin Corporation (Date incorporated _____________ )
6
Limited Liability Company – Enter date registered with the
4
Out-of-state Corporation (Licensed in Wis?
Yes
No)
Department of Financial Institutions: ______________________
For federal income tax purposes, will the LLC be taxed as a:
5a
Other (Describe _________________________________ )
Single member LLC dis-
Partnership
Corporation
regarded as a separate entity
7. Provide the following information for sole proprietor, all general partners if partnership, all members of a limited liability
company, or principal officers of a corporation.
Name
Social
Security
Home
Address
City,
State &
Zip Code
Title
è
THIS APPLICATION MUST BE SIGNED ON THE REVERSE SIDE
More
MF-100 (R. 4-03)
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Parent category: Financial