Form Mft-1r - Application For Renewal Of Seller - User'S License - 2000 Page 2

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Item number 10 must be completed by out-of-state businesses.

10. Give name, title and address of agent in New Jersey or registered New Jersey agent on whom service may be made (must be documented by letter

from agent) ______________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

11. List all suppliers of special fuels.

a. Name of supply source, street address, city, state, fuel type and FID # (REQUIRED)

__________________________________________________________________________ FID # _____________________________________

b. Names of Contract or Common Carriers who deliver fuel by tank truck or tank car __________________________________________________

_____________________________________________________________________________________________________________________

12. Has applicant ever had a New Jersey Motor Fuels License denied, suspended, canceled or revoked?

¨ Yes

¨ No

If yes, explain ____________________________________________________________________________________________________________

13. List the location of applicant’s storage tank(s), its physical address, type of facility*, storage capacity, whether the property on which the facility

rests is owned or leased, and whether the pumps are metered or not.

Total Fuel

Properties

Fuels Delivered (thru)

a. Trade Name

State Kind of

Storage Capacity

Owned (O)

Metered

Unmetered

b. Street Address

City

County

Storage Facilities *

(Gallons)

Or Leased (L)

Pumps

* Overhead or underground tanks, skid tanks, or drums. Trucks are considered storage for home heating oil.

The undersigned applicant states, (under penalty of perjury), that all the information contained in this application is true and accurate in every particular.

________________________________________________________

_________________________________________________________

Name of Applicant

Signature of Owner, Partner or Officer

_________________________________________________________

Title

Date

All information must be provided before the application can be processed.

Return completed application and $150 fee to:

MOTOR FUEL TAX, PO Box 189, Trenton, NJ 08695-0189

There is no fee to holders of valid New Jersey Motor Fuel Retail Dealer, Wholesale Dealer, or Distributor Licenses.

The information submitted will assist this office in the processing of your request.