Form Mf-40 - Application For Lp-Gas User - Dealer License
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1
2Fee Enclosed
FOR OFFICE USE—LEAVE BLANK
KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
MAKE REMITTANCE PAYABLE TO
Validation No.
TOPEKA, KANSAS 66625-8000
License No.
"DIRECTOR OF TAXATION—MFT"
Date License Issued
Phone Number: (785) 368-8222
Date Mailed
Fax (785) 296-4993
APPLICATION FOR LP-GAS USER - DEALER LICENSE
1.
Business name
2.
Business mailing address
Street Address or Post Office Box
City
State
Zip Code
3.
Business location address
Street Address
City
County
State
Zip Code
4.
Federal Employers Identification Number
5.
Business Phone Number
(
)
FAX Number (
)
T Individual
T Partnership
T Corporation
T Other
6.
Check type of ownership:
7.
List owner, partners, corporate officers and all stockholders who own 5% or more of company stock.
Social Security
Telephone
Name
Address
Title
Number
Number
8.
List the exact location of each place in Kansas where applicant intends to operate as an LP-Gas User or Dealer, placing LP-Gas in
fuel tanks of motor vehicles.
For Office Use Only
Street Address
City
County
Location No.
1.
2.
3.
4.
T
T
9.
Is a Dealer or User license in effect for another at the above location?
Yes
No
10. If a successor to a former Dealer or User, give trade name of such User/Dealer
11. Indicate whether location is owned or leased by the applicant
12. List name and telephone number of a contact person for tax return inquiries
Applicant agrees to comply with the provisions and requirements of the LP-Gas tax law and the rules and regulations promulgated by
the Director of Taxation.
State of
County of
,
ss:
I,
, first being fully sworn, state that the above application and all
statements contained therein, are true and correct.
(Signature of Owner, Partner, Corporate Officer, or Person Authorized by a Power of Attorney)
(Title)
Subscribed and sworn to before me, this
day of
, 20
__.
My commission expires
, 20
Notary Public
MF-40
(Rev. 4/04)
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Parent category: Financial