Form Wv/mft-App - West Virginia Motor Fuel Excise Tax License Application Page 3
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4K. DISTRIBUTOR INFORMATION
If you are applying for a distributor’s license, you must complete this section.
1. Will you import motor fuel into West Virginia from a permissive supplier?
□ Yes
If yes, you must complete Section M – Importer Information.
□ No
2. Will you export motor fuel from West Virginia?
□ Yes
If yes, you must complete Section L – Exporter Information.
□ No
3. Will you purchase motor fuel for resell from a supplier or another distributor?
□ Yes
□ No
L. EXPORTER INFORMATION (Attach additional pages if necessary.)
If you plan to export motor fuel from West Virginia, you must complete this section.
1. What mode of transportation will you use to export from West Virginia? (Check all applicable boxes.)
□ Transport Vehicle
□ Railroad Tank Car
□ Other _______________________________________________
2. Will you purchase motor fuel from a licensed supplier and/or distributor?
□ Yes
□ No
3. Will you export motor fuel from a bulk plant?
□ Yes
□ No
4. List the state(s) to which you plan to export motor fuel and the License or Registration Number for each of those state(s).
State
License/Registration Number
State
License/Registration Number
State
License/Registration Number
1.
3.
5.
2.
4.
6.
M. IMPORTER INFORMATION (Attach additional pages if necessary.)
If you plan to import motor fuel into West Virginia, you must complete this section.
1. Will you import motor fuel that you receive from a permissive supplier?
□ Yes
□ No
If No, you will be licensed as an importer, required to obtain a bond in the amount of (minimum of $100,000 and a maximum of $2,000,000), and report
monthly.
2. What mode of transportation will you use to import into West Virginia? (Check all applicable boxes.)
□ Transport Vehicle
□ Railroad Tank Car
□ Other _______________________________________________
3. Do you plan to import motor fuel from a bulk plant located in another state?
□ Yes
If Yes, you will be licensed as an importer, required to obtain a bond in the amount of (minimum of $100,000 and a maximum of $2,000,000), and report
monthly.
□ No
4. List the state(s) from which you plan to import motor fuel and the License or Registration Number for each of those state(s).
State
License/Registration Number
State
License/Registration Number
State
License/Registration Number
1.
3.
5.
2.
4.
6.
N. MOTOR FUEL TRANSPORTER INFORMATION
If you plan to transport motor fuel, you must complete this section.
1. Will you transport motor fuel (Check all boxes that apply)
□ For import into West Virginia?
□ For export from West Virginia?
□ From point to point within West Virginia?
2. What mode of transportation will you use?
□ Marine Vessel
□ Transport Vehicle
□ Railroad Tank Car
O. STORAGE FACILITY INFORMATION (Attach additional pages if necessary.)
Complete the following for motor fuel storage facilities you own and/or lease. (Include facilities that are currently not in use)
OWN
Storage
Terminal Control Number
Physical Location
Product
How will motor fuel be received? (explain)
Capacity
(If fuel is stored at a terminal)
(Street Address, City, State)
Code
(gallons)
LEASE
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