Fillable Form Mft-3a - Application For Exporter'S License

14. Is applicant a licensed distributor, importer or exporter in another state or foreign country. Please indicate state, license number, and point of contact in

each state (to include name and telephone number). Additionally, please attach a copy of each license. If applicant is a foreign importer, include copy

of US Customs permit.______________________________________________________________________________________________________

15. Does applicant hold a Federal Form 637? If so, identify the issuing IRS District Office, provide copy of 637 certificate and also copies of applicant’s last

two quarterly Form 720 reports filed with the IRS. _________________________________________________________________________________

16. Does applicant hold any other New Jersey Motor Fuels License? If yes, explain _________________________________________________________

________________________________________________________________________________________________________________________

17. Has applicant ever had a New Jersey Motor Fuel License denied, suspended, canceled or revoked in New Jersey or any other jurisdiction? If yes,

explain:__________________________________________________________________________________________________________________

18. Does applicant have any outstanding liability or litigation? If yes, explain ______________________________________________________________

________________________________________________________________________________________________________________________

19. Indicate below the maximum number of gallons of motor fuels that you expect to import into this state and the maximum number of gallons of motor fuels

you expect to purchase within this state in any month.

EXPORTS______________________ Gal.

NJ PURCHASES _______________________ Gal.

TOTAL HANDLE ___________________ Gal.

NOTE:

An “exchange” or “book transfer” of gasoline in this State is a purchase and or sale and must be reported by seller and purchaser. Reference:

N.J.S.A. 54:39-7.

20. Type of motor fuels to be handled and percentage of each.

__________________________ ________%

_____________________________ ________%

21. Describe in detail applicant’s planned activity and need for this license ________________________________________________________________

________________________________________________________________________________________________________________________

22. Indicate below by which type of carrier you expect to receive import motor fuels into this State.

! Tanker

! Pipeline (provide copy of agreement)

! Barge

! Tank Car

! Tank Truck

23. List below each manufacturing plant, wholesale plant (to include any leased storage) and retail station operated in New Jersey. Designate each by using

“W” for wholesale, “R” for retail and “L” for leased. (If more space is needed, attach rider)

Location

Class - M, W, R, L

Number of Tanks

Total Capacity Gallons

24. Qualification for an Exporter License may be predicated upon applicant meeting the test of an Exporter. An Exporter License is required by any person

who acquires title or takes delivery of fuels within New Jersey and subsequently exports such fuels from the State.

25. Is applicant registered for Petroleum Products Gross Receipts as required by the Act? .......................................... ! YES

! NO

26. Is applicant registered with the Division of Taxation for any other New Jersey State taxes?.................................... ! YES

! NO

27. The undersigned applicant states, (under penalty of perjury), that all the information contained in this application is true and accurate in every particular.

_________________________________________________________

___________________________________________________

Name of Applicant

Signature of Owner, Partner or Officer

___________________________________________________

Title

Date

The information submitted will assist this office in the processing of your license request.

The Division of Taxation reserves the right to conduct a thorough investigation prior to issuing this license.

FOR DIVISION USE ONLY

License No. _______________________________________________

Investigation initiated __________________________________