Form 795 - Missouri Motor Fuel Tax License Application - 2006 Page 2
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MISSOURI DEPARTMENT OF REVENUE
DOR USE ONLY — LICENSE NUMBERS
CUSTOMER SERVICES DIVISION
FORM
SUPPLIER/PERMISSIVE SUPPLIER ______________________________
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
795
DISTRIBUTOR _______________________________________________
(573) 751-2611
TDD 1-800-735-2966
TRANSPORTER ______________________________________________
MISSOURI MOTOR FUEL TAX LICENSE
(REV. 11-2006)
TERMINAL OPERATOR ________________________________________
APPLICATION
ELIGIBLE PURCHASER
YES
NO
LIST LICENSE NUMBER IF MAKING A CHANGE
NEW APPLICATION
CHANGE
REINSTATEMENT
OR REQUESTING REINSTATEMENT:
SECTION 1 — BUSINESS NAME AND LOCATION
MITS NO.
IRS 637 NUMBER
FEIN NO.
DO YOU HAVE INTERNET ACCESS?
YES
NO
BUSINESS NAME
INTERNET SITE ADDRESS (WEB PAGE)
DBA NAME
E-MAIL ADDRESS
PHYSICAL LOCATION OF BUSINESS
CITY, STATE, ZIP CODE
COUNTY
TELEPHONE
BUSINESS MAILING ADDRESS
CITY, STATE, ZIP CODE
COUNTY
FAX
BOOKS AND RECORDS ADDRESS
CITY, STATE, ZIP CODE
COUNTY
NAME OF CONTACT PERSON
HOW DO YOU WANT TO RECEIVE REPORTING FORMS AND UPDATES?
I will download from the Internet.
I would like an e-mail reminder when
reports are due.
(CHECK ONE)
Please mail forms on a yearly basis.
SECTION 2 — CONTACT PERSONS
Companies that use accounting firms to file applications, bonds or reports must submit an original Power of Attorney for that person before we may release information to the
accounting firm. If someone other than an officer of the company signs the application or bond form, a Power of Attorney must be provided for that person. If you complete your
applications and reports within your company, please indicate the contact person responsible for each activity.
CONTACT PERSON
FOR REGISTRATION
_________________________________________________
TELEPHONE NUMBER
__________________________
E-MAIL ADDRESS: ___________________________
CONTACT PERSON
REPORTING
_________________________________________________
TELEPHONE NUMBER
__________________________
E-MAIL ADDRESS: ___________________________
SECTION 3 — TYPE OF ACTIVITY — CHECK ALL THAT APPLY
SUPPLIER/POSITION HOLDER IN A MISSOURI TERMINAL (OWNS PRODUCT IN THE TERMINAL FOR SALE OR EXCHANGE)
EXPORT FUEL FROM MISSOURI
LIST STATE(S) AND LICENSE NUMBER(S)
_______________________________________________________________________________
PARTICIPATE IN EXCHANGES
LIST EXCHANGE PARTNERS
_______________________________________________________________________________
EFFECTIVE DATE FOR LICENSE
____________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 16
PERMISSIVE SUPPLIER/POSITION HOLDER IN AN OUT-OF-STATE TERMINAL (OUT-OF-STATE SUPPLIER THAT ELECTS TO HAVE A SUPPLIER’S LICENSE)
EFFECTIVE DATE FOR LICENSE
____________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 13, 15 AND 16
TERMINAL OPERATOR/OPERATING A MISSOURI TERMINAL (OWNS, OPERATES OR CONTROLS A TERMINAL)
TYPE OF TERMINAL
BARGE
PIPELINE
DO YOU COMMINGLE PRODUCTS WITH THOSE OF ANY OTHER COMPANY?
YES
NO
IF YES, LIST COMPANY NAME(S) ________________________________________________
EFFECTIVE DATE FOR LICENSE
____________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 9, 12, 15 AND 16
DISTRIBUTOR (IMPORTS, EXPORTS OR BLENDS MOTOR FUEL AND MAY QUALIFY AS AN ELIGIBLE PURCHASER AUTHORIZED TO PURCHASE ON A TAX DEFERRED BASIS)
IMPORTS — LIST NAME OF STATE(S) AND LICENSE NUMBER(S) ___________________________________________________________________________________________________________
EXPORTS — LIST NAME OF STATE(S) AND LICENSE NUMBER(S) __________________________________________________________________________________________________________
BLENDS — LIST TYPES OF FUELS BLENDED ____________________________________________________________________________________________________________________________
MY COMPANY WISHES TO QUALIFY FOR “ELIGIBLE PURCHASER” STATUS AS PROVIDED FOR UNDER SECTION 142.848, RSMo, TO PURCHASE FUEL ON A TAX DEFERRED BASIS.
EFFECTIVE DATE FOR LICENSE
____________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 11 AND 14 THROUGH 16
TRANSPORTER (OPERATES A PIPELINE, BARGE, RAILROAD OR TRANSPORT TRUCK TRANSPORTING FUEL IN MISSOURI)
DO YOU TRANSPORT FUEL FOR HIRE IN MISSOURI?
YES
NO
EFFECTIVE DATE FOR LICENSE
____________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 11, 15 AND 16
SECTION 4 — TYPE OF PRODUCT — CHECK ALL THAT APPLY
GASOLINE
GASOHOL
ALCOHOL
AVIATION GASOLINE
JET FUEL
UNDYED DIESEL FUEL
DYED DIESEL FUEL
UNDYED KEROSENE
DYED KEROSENE
ETHANOL
BIODIESEL
DYED BIODIESEL
OTHER _____________________________________
MO 860-0671 (11-2006)
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