Form Ma - Master Application - Montana - 2008
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1
2One-Stop Licensing
MONTANA
PO Box 8003
Form MA
Master Application
Helena, MT 59604-8003
Rev. 08-08
Phone: Toll free at (866) 859-2254 (in Helena, 444-6900)
FAX: (406) 444-0722
Company or Owner Name: _____________________________________________________________________________________
Federal Employer Identifi cation Number (FEIN) or Social Security Number: _______________________________________________
_______________________________________________________
_______________________
___________
___________
Business Location Address (cannot be a post offi ce box)
City
State
ZIP + 4
______________________________________________
_____________________________
___________________________
County
Business Phone
Fax Number
_______________________________________________________
_______________________
___________
___________
Business Mailing Address (if different from location address)
City
State
ZIP + 4
All coordinating applications/affi davits must be completed and attached for processing
License Fees
Food Purveyor (pages 4-6)
Large
Small
Meters-Petroleum Dealers (page 14)
Endorsements: (Check all that apply)
PA _____ x $21.00 = __________
01.
02.
03.
04.
06.
07.
08.
PB _____ x $70.00 = __________
PC _____ x $83.00 = __________
09.
10.
11.
12.
$ _______________
PD _____ x $102.00 = __________
Tobacco Products (page 7)
$ _______________
Retailer $5
Vendor $50
Scales-Weighing Devices (page 14)
Wholesaler $50
Subjobber $50 $ _______________
S1 or SA _____ x
$16.00 = ________
S2 or SB _____ x
$26.00 = ________
Off-Premises Beer/Wine License (pages 8-11)
S3 or SC _____ x
$51.00 = ________
Process Fee: Off-Premises $100.00
S4 or SD _____ x $130.00 = ________
S5 or SE _____ x $225.00 = ________
$ _______________
Off-Premises Beer $200.00 (if new)
$ _______________
Off-Premises Wine $200.00 (if new)
Total Amount Due
$ _______________
Off-Premises Beer/Wine $400.00 (if new)
$ _______________
Check or Money Order # ________________________________
Nursery License (page 12)
Make payable to “One-Stop Business Licensing”
$95.00 License Fee
$25.00 Application Fee
Credit Card Payment:
Visa
MasterCard
$ _______________
Underground Storage Tanks (page 13)
Credit Card #
<= 1100 gallons ______ x ______ = _________
$ 36
Expiration Date _______________________________________
>
1100 gallons ______ x ______ = _________
$108
$ _______________
Name on Card ________________________________________
Please Do Not Send Cash
The applicant is a: (check one and complete where appropriate)
S corporation
Individual
Limited Liability Company
Association (attach names and addresses)
C corporation
Limited Liability Partnership (attach names and addresses)
Partnership (attach names and addressess)
Nonprofi t C corporation
Assumed Business Name/DBA/Trade Name, Etc.: ___________________________________________________________________
Description of business transacted under the assumed business name: __________________________________________________
Date applicant fi rst used the assumed business name (Mo\Day\Yr): _____________________________________________________
E-mail address (optional): ______________________________________________________________________________________
Signature (of sole proprietor, all partner(s), corporate offi cer(s), or limited liability manager(s) or member(s).)
I(we), the undersigned, declare under the penalties of perjury and/or the revocation of any license granted, that I(we) am(are)
the applicant(s) or authorized representative(s) of the fi rm making this application and that the answers contained, including any
accompanying information have been examined by me(us) and that the matters and things set forth are true, correct and complete.
Signature(s) required (If a corporporation, corporate offi cer must sign)
Title
Date
__________________________________________________________
_____________________________
_________________
__________________________________________________________
_____________________________
_________________
Names and home addresses of all owners on the application are required. For corporations, the names and home addresses of the
corporation’s principal executive offi cers (president, vice-president, secretary and treasurer) and members of the board of directors are
required. (Attach additional sheet if necessary.)
Name
Home Address
Title
__________________________________________________
________________________________________
_______________
__________________________________________________
________________________________________
_______________
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Parent category: Business