Form Mf-53 - Application For Motor Fuel Retailers License
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2FOR OFFICE USE—LEAVE BLANK
KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
License No.
915 SW HARRISON ST.
Date License Issued
TOPEKA, KANSAS 66612-1588
Phone: (785) 368-8222
Date Mailed
Fax: (785) 296-4993
APPLICATION FOR MOTOR FUEL RETAILERS LICENSE
1.
B usiness 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
T
6. Check type of ownership:
___ Individual
___ Partnership
___ Corporation
Other
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 storage capacity and fuel type.
9. List number of gasoline/gasohol pumps
List number of clear diesel pumps
List number of dyed diesel pumps
10. List your Motor Vehicle and Special Fuel Distributors' License Number (if applicable)
11. Will you be selling fuel to the end user that will be applying for a refund of the motor fuel tax?
___ Yes
___ No
If yes, please enclose a copy of your company's complete invoice (original and all copies). See instructions on the
reverse side of this form.
12. Are the applicant(s) at least 18 years of age?
___ Yes
___ No
13. Do you or any partner, corporate officer or stockholder owning more than 5% of company stock owe any motor fuel
taxes, interest or penalty to a taxing agency in any state or the federal government?
___ Yes
___ No
14. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of
a felony involving theft within 5 years immediately preceding the date of making application in this or any other
jurisdiction?
___ Yes
___ No
15. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of
a felony involving fraud or tax evasion in this or any other jurisdiction?
___ Yes
___ No
16. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock had a motor fuel
license revoked for cause in another state?
___ Yes
___ No
17. Do you or any partner, corporate officer or stockholder owning more than 5% of company stock intend to carry on the
business authorized by the license as agent of another?
___ Yes
___ No
18.
If you answered yes to any question 13-17, please explain on a separate sheet of paper.
19.
Contact person for tax return inquiries:
Name: ___________________________________
Phone Number: _______________________________
Fax Number: ______________________________
E-Mail Address: _______________________________
MF-53
(Rev. 6/13)
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