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Form Pdo-101 - Application For Distributor'S License - Minnesota Department Of Revenue

PDO-101

Application for Distributor's License

Are you taking over an existing business?

Yes

Name of former operator:

Company name

Minnesota tax ID number

Estimated monthly gallonage:

I certify that I qualify as a distributor in accordance with the items checked

below:

Street

Federal ID number

Receive petroleum products in Minnesota that are

consigned to me from a terminal or refinery for storage

City

State

Zip code

and subsequent distribution by tank car or tank truck. [4]

Produce, manufacture or refine petroleum products in Minnesota. [5]

Import petroleum products into Minnesota by boat,

Check one:

Individual

Partnership

Corporation

barge or pipeline for storage and subsequent delivery. [6]

Hold a license and perform a function in an adjoining state

equivalent to that of a distributor under Minnesota law. [7]

State

License number

Authorized signature

Title

Date

Daytime phone

License fee of $25 must accompany this application. Make check payable to Minnesota Revenue and mail to:

(

Minnesota Revenue, Mail Station 1510, St. Paul, MN 55146-1510. Phone: 651-296-0889. Minnesota Relay 711

TTY).

Form Pdo-101 - Application For Distributor'S License - Minnesota Department Of Revenue