Form 795 - Missouri Motor Fuel Tax License Application - 2006 Page 3
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SECTION 5 — TYPE OF OWNERSHIP
Please indicate your ownership type.
Sole Owner (may include spouse)
Partnership
Limited Partnership – LP Number _____________________________________
Limited Liability Partnership – LLP Number _____________________________
Limited Liability Limited Partnership – LLLP Number _______________________________________________
Government
Not required to register with Missouri Secretary of State
Trust
Date Incorporated: _______________
Missouri Corporation – Missouri Charter No. ____________________________________
Non-Missouri Corporation – Certificate of Authority No. ___________________________
State of Incorporation and Date Registered in
Limited Liability Company:
Missouri _______________________
Taxed as a Partnership
Taxed as a Sole Owner
Taxed as a Corporation
LLC Number __________________________________
Other _______________________
_________________________________________________________________________________________
SECTION 6 — OWNERSHIP INFORMATION – PROVIDE INFORMATION FOR SOLE PROPRIETOR, ALL PARTNERS, ALL MEMBERS
OF ANY PARTNERSHIPS OR PRINCIPAL OFFICERS OF ANY LLC OR CORPORATION (Attach a list if necessary.)
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO
EFFECTIVE DATE
BIRTHDATE
HOME ADDRESS
CITY, STATE, ZIP
ENDING DATE
COUNTY
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO
EFFECTIVE DATE
BIRTHDATE
HOME ADDRESS
CITY, STATE, ZIP
ENDING DATE
COUNTY
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO
EFFECTIVE DATE
BIRTHDATE
HOME ADDRESS
CITY, STATE, ZIP
ENDING DATE
COUNTY
SECTION 7 — PREVIOUS OWNERSHIP INFORMATION (COMPLETE ONLY IF YOU PURCHASED AN EXISTING BUSINESS)
NAME OF PREVIOUS OWNER OF BUSINESS
BUSINESS NAME
DATE BUSINESS CLOSED OR CHANGED OWNERSHIP (MONTH/YEAR)
LICENSE NUMBER(S)
SECTION 8 — NAMES OF ANY PERSONS ASSOCIATED WITH THIS COMPANY WHO PRESENTLY OR PREVIOUSLY OWNED,
OPERATED OR MANAGED ANOTHER MOTOR FUEL COMPANY (ATTACH ADDITIONAL SHEET IF NEEDED)
COMPANY NAME
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO.
BIRTHDATE
HOME ADDRESS
CITY
STATE
ZIP CODE
LICENSE NUMBER(S)
COMPANY NAME
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
SOCIAL SECURITY NO.
BIRTHDATE
HOME ADDRESS
CITY
STATE
ZIP CODE
LICENSE NUMBER(S)
SECTION 9 — FUEL SUPPLIERS/CUSTOMERS/POSITION HOLDERS (ATTACH LIST IF NECESSARY)
SUPPLIERS — List from whom you purchase fuel; DISTRIBUTORS—List your suppliers; TRANSPORTERS—List those for whom you contract to haul fuel; TERMINAL
OPERATORS—List all position holders in your terminal.
NAME OF
FEDERAL I.D.
LICENSE
PRODUCT
TERMINAL NUMBER WHERE
HOW PRODUCT
ACTIVITY TYPE
PHONE NUMBER
SUPPLIER/CUSTOMERS
NUMBER
NUMBER
TYPE
PRODUCT IS RECEIVED
IS RECEIVED
SECTION 10 — LIST ALL COMMON CARRIERS YOU HIRE TO TRANSPORT FUEL
TRANSPORTER NAME
PHONE NUMBER
FEDERAL I.D. NUMBER
LICENSE NUMBER
MODE
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