Form 72a300 - Tax Registration Application For Motor Fuels License
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472A300 (09-10)
TAX REGISTRATION APPLICATION FOR MOTOR FUELS LICENSE
Commonwealth of Kentucky
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DEPARTMENT OF REVENUE
SECTION 1—GENERAL INFORMATION (Must be completed by all applicants.)
1. Check the license type for which this registration application is completed.
Gasoline Dealer's License (Complete Sections 2, 3, 4, 5 and 6.)
Terminal Owner-Operator (Complete Section 10.)
Special Fuels Dealer's License (Complete Sections 2, 3, 4 and 5.)
Motor Fuels Transporter's License (Complete Section 9.)
Liquefi ed Petroleum Gas Dealer's License (Complete Sections 2, 7 and 8.)
2. Check the reason for completing this application.
New Applicant
Other (specify reason)
Information Update
3. Legal Business Name
4. Do you operate this business under any other name?
Yes
No
If yes, provide other name
5. Nature of Business (Provide an accurate description of this business's principal activity(ies) performed or product(s)
manufactured.)
6. Check the type of current ownership.
Individual
Partnership (Attach a copy of the partnership agreement.)
/
Corporation
LLC
Date of Incorporation
State of Incorporation
(If state is other than Kentucky, see Item 15(B) below.)
Provide owner and/or corporate offi cer details below, or if corporations have joined in a partnership, attach a list of each
qualifying corporation and corresponding corporate offi cer details.
Last Name
First Name
M.I.
Title
Residence Address
Social Security Number
7. Does the applicant have any interest in any current or former motor fuels license or had any license or permit suspended,
cancelled or revoked?
Yes
No (If yes, attach a complete written explanation.)
8. Mailing Address and Telephone Number
(
)
–
P.O. Box or Number and Street/Highway
City
State
ZIP Code + 4
Telephone Number
(
)
–
Fax Number
Contact E-mail Address
9. Kentucky Business Location and Telephone Number (If more than one Kentucky location, attach list of all.)
(
)
–
Number and Street/Highway
City
County
State
ZIP Code + 4
Telephone Number
10. Address Where Records are Available for Audit and Telephone Number
(
)
–
Number and Street/Highway
City
State
ZIP Code + 4
Telephone Number
/
/
11. Give the date motor fuel activity began or will begin in Kentucky.
Month
Day
Year
12. Does or will your company have the capability to remit payments by electronic funds transfer?
Yes
No
Does or will your company have the capability to submit data via electronic fi ling programs?
Yes
No
If yes, will payment be remitted from a bank located outside the U.S.?
Yes
No
13. Check and list major federal and state account numbers held by this business.
–
Federal Employer ID Number
Corporation Income Tax Number
KY Highway User (KYU) Number
Sales and Use Tax Number
KY Unemployment Insurance Number
Withholding Tax Number
14. List previous ownership data.
Name Under Which Business Operated
Owner Name and Current Address
(
)
–
Telephone Number
Motor Fuels Tax License Number(s)
15. Required Attachments:
(A) Applicants for new license must attach either an executed corporate surety bond on Revenue Form 72A301, a line of credit letter,
or provide documentation for an account with a fi nancial institution maintaining a compensating balance.
(B) Nonresident corporations must attach a certifi ed copy of their Certifi cate of Authorization to transact business in Kentucky issued
by the Kentucky Secretary of State. For information, contact the Secretary of State's offi ce at (502) 564-3490.
(C) Attach a certifi ed fi nancial statement.
File only one application. For assistance, call (502) 564-3853, fax (502) 564-2906. Mail completed application and all attachments to: Motor Fuels
Tax Section, P.O. Box 1303, Station 63, Frankfort, KY 40602-1303. Overnight delivery 501 High Street, Frankfort, KY 40601.
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