Form Wv/mft-App - West Virginia Motor Fuel Excise Tax License Application
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4WEST VIRGINIA MOTOR FUEL EXCISE TAX
WV/MFT-APP
REV 4/09
LICENSE APPLICATION
Please read instructions prior to completing application
PLEASE PRINT IN INK OR TYPE
A. APPLICANT INFORMATION
Legal Business or Corporation Name
FEIN/SSN
Trade Name or DBA (if different from Business Name)
Federal Certificate of Registry Number
Contact Person
Telephone Number
Fax Number
E-mail Address
(
)
(
)
B. ADDRESS INFORMATION
Physical Location (do not list P.O. Box)
City
State
Zip Code
Mailing Address (if different from above)
City
State
Zip Code
Address for Business Records
City
State
Zip Code
C. LICENSE INFORMATION (Attach additional pages if necessary.)
Check each license for which you are applying
□ Supplier/Refiner
□ Importer
□ Terminal Operator
□ Motor Fuel Transporter
□ Permissive Supplier
□ Exporter
□ Blender
□ Distributor
List business license number(s) for the following (if applicable)
IFTA
IRP
WV MCRT
License number:
License number:
License number:
Enter 5-digit Control Number assigned by the Secretary of State’s Office, if applicable.
You must have a control number to submit this application, except for sole proprietorship or general partnership.
D. TYPE OF BUSINESS OWNERSHIP
□ Sole-Owner
□ General Partnership
□ Joint Venture
□ Other (specify below)
□ Domestic Corporation
□ Limited Partnership
□ Association
□ Foreign Corporation
□ Limited Liability Partnership
□ Limited Liability Company
CORPORATION: provide all corporate officers. PARTNERSHIP: provide all partners. SOLE PROPRIETORSHIP: provide owner.
ALL OTHERS: provide all general partners, members, or managers. (Attach additional pages if necessary.)
Full Legal Name
Title
Social Security Number
Home Address
City
State
Zip Code
Full Legal Name
Title
Social Security Number
Home Address
City
State
Zip Code
If your business organization is a partnership, sole proprietorship, or your business is based in another state you must provide an agent for service of process.
If you are applying for an Exporter’s License, you must provide a West Virginia Registered Agent.
Name
Address
City
State
Zip Code
Telephone Number
E-mail address
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)
Fax Number
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*O58040901w*
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Parent category: Financial