Form Rt 111 - Application For Motor Fuel And Petroleum Products Transporter'S License
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1STATE OF NEW HAMPSHIRE
OFFICE USE ONLY
DEPARTMENT OF SAFETY
LICENSE NO._____________
ROAD TOLL BUREAU
33 HAZEN DRIVE, CONCORD NH 03305
ISSUED_________________
TELEPHONE: (603) 271-2311
TDD Access: Relay NH 1-800-735-2964
CANCELLED______________
-FY2010-
APPLICATION FOR MOTOR FUEL AND PETROLEUM PRODUCTS TRANSPORTER’S LICENSE
FEIN NUMBER: ______________________
NAME: _______________________________________________________________________________________________
TELEPHONE NUMBER
ADDRESS: ____________________________________________________________________________________________
NO. AND STREET
CITY/TOWN
STATE
ZIP
LOCATION WHERE RECORDS WILL BE AVAILABLE FOR AUDIT:
________________________________________________________________________________________________________________
NO. AND STREET
CITY/TOWN
STATE
ZIP
CONTACT NAME: __________________________________________________ EMAIL ADDRESS: _____________________________________________
RSA 260:42 Motor Fuel and Petroleum Products Transporter
I.
Every person not registered as a distributor who transports motor fuel or products subject to the fees stipulated in RSA 146-A, to a point or
points within the state from a point or points outside the state, every common carrier or contract carrier who transports motor fuel or petroleum
products, and every licensed distributor who transports motor fuel or petroleum products exclusive of the carrier's own product shall be
licensed with the commissioner as a motor fuel and petroleum products transporter.
IV.)
The commissioner shall issue a license certificate when the application has been accepted and approved, and all other conditions and
requirements of this subdivision have been fully complied with. The license shall be valid only for the transporter in whose name it is issued.
The license shall not be assignable and shall remain in full force and effect on a fiscal year basis from July 1 through June 30 unless cancelled,
suspended, or revoked. The license shall be renewable upon completion of an application renewal form, provided that the transporter is in
good standing with the division.
V.)
The transporter shall report to the commissioner on forms prescribed by the commissioner, not later than the twentieth of the succeeding
calendar month, subject to prosecution for unsworn falsification, all deliveries of motor fuel and petroleum products made to points within the
state during the previous calendar month. Such reports shall contain sufficient information to identify the quantities delivered, the consignor,
the consignee and such additional information as the commissioner may require. A report shall be filed for any month in which no activity
occurs.
VI.)
(a). Any person who fails, neglects, or refuses to file the monthly report required by this section shall be assessed a penalty of $500. Such
penalty shall immediately accrue and shall bear interest as specified in RSA 260:40-a.
(b) Any person who fails to report a delivery of petroleum fuel or petroleum products within the time period specified in this section
shall be assessed a penalty of $500 or $50 per unreported delivery, whichever is greater. Such penalty shall immediately accrue and
shall bear interest as specified in RSA 260:40-a.
SIGNED:__________________________________________________
"
This application is signed under penalty of unsworn falsification pursuant to RSA 641:3."
TITLE:___________________________________________________
AUTHORIZED REPRESENTATIVE
RT 111 (Revised 5/09)
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