Form Gas-1262 - Motor Fuels Application - North Carolina Department Of Revenue - 2008 Page 7

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(Fill in applicable circle for title)

Manager

Member

Vice-President

Partner

Co-Owner

Full Name (First, Middle, Last)

Residence Address (Street address, City, State, and Zip code)

11.

Telephone (Business)

10. Telephone (Residence)

13.

Driver’s License Number & State

12. Social Security Number

(Fill in applicable circle for title)

Manager

Member

Secretary

Partner

14.

Full Name (First, Middle, Last)

15.

Residence Address (Street address, City, State, and Zip code)

17.

Telephone (Business)

16. Telephone (Residence)

19.

Driver’s License Number & State

18. Social Security Number

(Fill in applicable circle for title)

Treasurer

Manager

Member

Partner

20.

Full Name (First, Middle, Last)

21.

Residence Address (Street address, City, State, and Zip code)

23.

Telephone (Business)

22. Telephone (Residence)

25.

Driver’s License Number & State

24. Social Security Number

26. List full name of directors (Attach additional sheets if necessary.)

Address (Mailing address, City, State, and Zip code)

27. List full name of shareholders with controlling interest in corporation

Address (Mailing address, City, State, and Zip code)

If there are 15 or less shareholders, all shareholders have a controlling interest. If there are more than 15 shareholders, shareholders with 5% or more

owner-

ship have a controlling interest.

28. Has the corporation, LLC, LLP, partnership, or any officers, members, controlling shareholders of the corporation or owners of the business

been convicted of any felony or misdemeanor involving motor fuels?

Yes

(If yes, please explain.)

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