Form Gas-1262 - Motor Fuels Application - North Carolina Department Of Revenue - 2008 Page 6
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Registration Application
Motor Fuel Tax License
PRINT
CLEAR
North Carolina Department of Revenue
Part 1. Identifying Information
LLP
Other(Identify)
1.
Type of Ownership:
Proprietorship
C Corp.
S Corp.
LLC
Partnership
Fiduciary
If a corporation or LLC, State of Incorporation
Date
Corporate or LLC Number
Attach copy of Articles of Incorporation, LLC or LLP Operating Agreement, Charter and Certificate of Authority To Do Business
2. Legal Name
3. Trade Name (DBA Name)
4. Business Location
Street
(Not P.O. Box Number)
State
City
Zip Code
County
5. Mailing Address
Street or P.O. Box
City
State
Zip Code
6. Email Address
7. Location of Records
Street
City
State
Zip Code
8. Licensing Contact
Name
Telephone Number
Fax Number
Name
9. Filing Contact
Telephone Number
Fax Number
10. Preparer Mailing Address
Name
Street or P.O. Box
State
City
Zip Code
Email Address
11. Federal Employer’s Identification Number (FEIN)
Part 2. Ownership Information
Each corporate officer, principal, manager, partner or owner must complete the information requested below.
If needed, attach additional sheet(s) to provide the information requested in this application.
(Fill in applicable circle for title)
President
Manager
Member
Partner
Owner
1.
Full Name (First, Middle, Last)
2.
Residence Address (Street address, City, State, and Zip code)
4.
Telephone (Business)
3.
Telephone (Residence)
6.
Driver’s License Number & State
5.
Social Security Number
I certify that, to the best of my knowledge, the information contained on Lines 1 through 6 is correct.
7.
Signature (Recommended for companies not publicly traded)
Page 5
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Parent category: Financial