Form 3712 - Motor Fuel Tax License Application 2009
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Michigan Department of Treasury
3712 (Rev. 7-09)
This form is issued under authority of P.A. 403 of 2000,
as amended. Filing is mandatory.
Motor Fuel Tax License Application
Failure to provide all information will delay
the processing of your application.
PART 1: IDENTIFYING INFORMATION
If a corporation or LLC, State of Incorporation
1. Type of Ownership:
Other:_____________
Individual
Partnership
Date Incorporated
Domestic Corporation
Foreign Corporation
Trust/Estate
LLC (Limited Liability Corporation)
Corporate or LLC Number (if applicable)
S. Corporation
LLP (Limited Liability Partnership)
2. Legal Name
3. Federal Employer Identification Number (FEIN), TR, or ME Number
5. Business Telephone Number
6. Business Fax Number
4. Trade Name (DBA)
7. Legal Address (Street, RR#, P.O. Box, City, State, ZIP)
8. Mailing Address (Street, RR#, P.O. Box, City, State, ZIP)
10. Licensing Contact
11. Tax Preparer Contact
9. Physical Location of Business (Not P.O. Box)
(name, telephone no., fax no., email)
(name, telephone no., fax no., email)
PART 2: OWNERSHIP INFORMATION
Lines 12-14 must be completed for each corporate officer, principal, partner or owner. Attach additional sheet(s) if necessary.
A.
B.
C.
D.
E.
Title
Full Name
Residence Address
Residence
Social
(first, middle, last)
(Street or RR#, city, state, Zip)
Telephone Number
Security Number
12.
13.
14.
15. Foreign Corporations: Name and Complete Address of Resident Agent
FEIN of Resident Agent
Telephone Number of Resident Agent
16. Date Motor Fuel Operations began in Michigan
17. Anticipated effective date of license(s) (MM/DD/YYYY)
18. This form must be signed by the owner, two partners or two corporate officers responsible for filing returns and making tax payments.
I declare under penalty of perjury, that I have examined this application, including accompanying schedules and statements, and to the best of my
knowledge, it is true and complete.
Signature
Printed Name
Title
Date
Signature
Printed Name
Title
Date
19a. License Type
19b. License Fee
Mail completed applications to:
Michigan Department of Treasury
Special Taxes Division
P.O. Box 30474
Lansing, MI 48909-7974
TREASURY USE ONLY
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