Form Wv/mft-App - West Virginia Motor Fuel Excise Tax License Application Page 4
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4Storage
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)
P. SERVICE STATION/RETAIL OUTLET INFORMATION (Attach Additional pages if needed.)
If you plan to own or lease service station/retail outlets in West Virginia, you must complete this section.
Own
Storage
Product
WV ID Number
Physical Location (Street Address)
City
Capacity
Code
(gallons)
Lease
Storage
Product
WV ID Number
Physical Location (Street Address)
City
Capacity
Code
(gallons)
Q. BONDING REQUIREMENTS (Check One)
1. □ Surety bond
2. □ Proof of financial responsibility
3. □ 18 months good filing status in lieu of 1 or 2
R. TAX PRE-COLLECTION AGREEMENT
Permissive Suppliers must complete this section.
I agree to collect the taxes due to the State of West Virginia on Motor Fuel that has West Virginia as its destination state and that was removed from a terminal located
in another state.
Authorized Representative’s Name (Please print or type)
Title
Authorized Representative’s Signature
Date
Telephone Number
Fax Number
E-mail Address
(
)
(
)
S. CERTIFICATION
ALL APPLICANTS MUST COMPLETE THIS SECTION
I CERTIFY THAT I HAVE READ THIS APPLICATION AND KNOW AND UNDERSTAND ITS CONTENTS AND THAT ALL THE INFORMATION
HEREIN IS TRUE AND ACCURATE. I UNDERSTAND IT IS UNLAWFUL TO KNOWINGLY MAKE A FALSE STATEMENT ON THE
APPLICATION AND THAT ANY VIOLATION MAY BE PROSECUTED.
Authorized Representative’s Name (Please print or type)
Title
Authorized Representative’s Signature
Date
Telephone Number
Fax Number
E-mail Address
(
)
(
)
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