Application For License (Page 3 of 4) in pdf

Application For License Page 3

8. Has the applicant, or any officer or director thereof, been found to have violated any applicable Navajo Nation or federal law within

the past 10 years?

Yes

If yes, explain :

9. Has the applicant, or any officer or director thereof, had any temporary or permanent suspension or revocation of any license or other

authorization pertaining to the distribution, carrying, transporation, refining, or retailing of fuel within the past 10 years?

Yes

If yes, explain :

10. Has the applicant been found to have violated any Navajo Nation or applicable federal law within the past 10 years, with a fine or

any other punishment constituting a violation?

Yes

If yes, explain :

11. Submit Proof of Insurance.

12. Submit proof that vehicles, storage tanks, etc. have been inspected and are in compliance with all applicable laws and regulations.

Include Vehicle Identification Number (VIN) or other identifying information for each vehicle.

13. Bond (Distributors Only)

Amount :

Date Posted with the Office of the Navajo Tax Commission :

Bonding Company :

14. Submit proof of certification of training in safety procedures (carriers and refiners only).

15. Submit proof of valid state or federal carrier's license (carriers only).

16. Submit list of all drivers authorized to use applicant's license (carriers only).

I declare that the information contained in this document and any attachments thereto is true and correct to

the best of my knowledge and belief pursuant to all Navajo Nation laws and regulations.

Taxpayer or Duly Authorized Agent Signature

Title

Print or Type Name

Date

Page 3 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

Application For License Page 3