Form Gas-1262 - Motor Fuels Application - North Carolina Department Of Revenue - 2008 Page 8
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2329. Name of bank or financial institution that you will use to pay the motor fuel tax:
Bank Account Number
Name
Street or P.O. Box
State
City
Zip Code
Fax Number
Telephone Number
30. List other business licenses or permits held by the corporation, LLC, partnership, or proprietorship
31. If your business is based in another state, list name, address, telephone number, and fax number of the North Carolina registered agent.
Name
Street or P.O. Box
State
City
Zip Code
Fax Number
Telephone Number
32. Indicate the states in which you do business.
33. Date business started in this state
/
/
for which a license is requested.
34. Has the corporation, LLC, LLP, partnership, or proprietorship now or in the past conducted any other businesses using a DBA?
Yes
No
(If yes, please list DBA used.)
35. Does the corporation, LLC, LLP, partnership, or proprietorship own any property in this state?
Yes
No
(If yes, please describe.)
36. Does any officer, director, member, controlling shareholder, partner, or owner own or control any petroleum business which operates in this
state or any other state (e.g., other refiners, suppliers, distributors, transportation company, retail outlets, terminal operations, etc.)?
Yes
No
(If yes, please explain.)
37. Does any officer, director, member, controlling shareholder, partner, or owner own or control any petroleum transport equipment which operates
in this state or any other state?
(If yes, please explain.)
Yes
No
38. List any current or previous officer, director, member, controlling shareholder, partner, or owner of any entity who holds or has held,
within the last seven years, a North Carolina motor fuel license.
State
Account Number
Relationship to account holder
Please provide the information requested
to the right for each person listed.
39. If business was acquired, from whom was it acquired?
List type of fuel and number of gallons in the storage tanks at the time of purchase. (Attach additional sheets if necessary.)
Aviation
Low Sulfur
Propane
Gasoline
Dyed Diesel
Gasoline
Jet Fuel
Ethanol
Dyed
Undyed
Methanol
Kerosene
Kerosene
Low Sulfur
Undyed
Alcohol
Diesel
Biodiesel
High Sulfur
Dyed
Gasohol
Dyed Diesel
Biodiesel
Page 7
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Parent category: Financial