Application For License
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1
2
3
4A
F
L
PPLICATION
OR
ICENSE
Initial Application:
Renewal:
If Renewal, please list current license number:
For Office Use Only
Type of License:
Date Received:
Processed By:
License Number:
Date Issued:
Payment Method:
Amount:
Posted By:
Check One (1) Only:
Separate applications must be completed for each type of license requested
DISTRIBUTOR
CARRIER
RETAILER
REFINER
1. Applicant's Corporate or Company Name :
Federal Employer's Identification Number (EIN)
2. Business/Mailing Address :
(Street Address, City, State)
Telephone No: (
)
Fax No: (
)
3. Physical Location of Business within the Navajo Nation :
(Street Address, City, State)
Land Status of Business Site :
Tribal Trust
Business Site Lease Number :
Allotment
Expiration Date :
Fee (Private)
Other (Explain)
4. Type of Business (Check One) :
Sole Proprietorship
Partnership
Governmental Entity or Enterprise
Corporation
Other (Explain)
5. Contact Person(s):
Telephone Number, if different from #2. Above.
Title :
(
)
Page 1 of 5
Office of the Navajo Tax Commission
P.O. Box 1903, Window Rock, AZ 86515
FET:
Ph: (928) 871-6681; Fax: (928) 871-7608
Application for License
Revised: 2/12/2002
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Parent category: Business