Form 795 - Missouri Motor Fuel Tax License Application - 2006 Page 4
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SECTION 11 — CONVEYANCE METHOD USED FOR TRANSPORTING FUEL
PIPELINE
BARGE
SHIP
RAILROAD
TRUCK
STATIONARY TRANSFER
OTHER
IF USING YOUR OWN TRANSPORT TRUCKS, LIST TRANSPORTATION EQUIPMENT (ATTACH LIST IF NECESSARY)
IF YOU WISH TO OBTAIN TANK WAGON PERMITS FOR ANY VEHICLES LISTED BELOW, PLEASE INDICATE BY PLACING A CHECK MARK IN THE LAST COLUMN.
STATE
VEHICLE IDENTIFICATION NUMBER
TOTAL CAPACITY
YEAR
MAKE/MODEL
TANK WAGON
REGISTERED
OR TRAILER SERIAL NUMBER
GALLONS
SECTION 12 — TERMINAL INFORMATION (Attach list if necessary)
T
-
;
-
;
-
-
ERMINAL OPERATORS LIST IN
STATE TERMINALS
SUPPLIERS LIST IN
STATE TERMINALS
PERMISSIVE SUPPLIERS LIST OUT
OF
STATE TERMINAL INFORMATION
1. TERMINAL STREET ADDRESS
TERMINAL CODE
CITY
STATE
ZIP CODE
T
–
–
2. TERMINAL STREET ADDRESS
TERMINAL CODE
CITY
STATE
ZIP CODE
T
–
–
3. TERMINAL STREET ADDRESS
TERMINAL CODE
CITY
STATE
ZIP CODE
T
–
–
4. TERMINAL STREET ADDRESS
TERMINAL CODE
CITY
STATE
ZIP CODE
T
–
–
5. TERMINAL STREET ADDRESS
TERMINAL CODE
CITY
STATE
ZIP CODE
T
–
–
6. TERMINAL STREET ADDRESS
TERMINAL CODE
CITY
STATE
ZIP CODE
T
–
–
7. TERMINAL STREET ADDRESS
TERMINAL CODE
CITY
STATE
ZIP CODE
T
–
–
SECTION 13 — NOTICE OF ELECTION (Suppliers/Permissive Suppliers Only)
THIS NOTICE OF ELECTION PROVIDES FOR THE PRECOLLECTION OF THE MISSOURI MOTOR FUEL TAX ON ALL REMOVALS FROM ALL OUT-OF-STATE
TERMINALS LISTED ABOVE WHERE SUPPLIERS OR PERMISSIVE SUPPLIERS ARE POSITION HOLDERS.
We elect to treat all removals from all out-of-state terminals with a destination into Missouri as shown on the terminal-issued shipping papers as if
the removals were removed across the rack by the supplier from a terminal in Missouri as provided in Section 142.839, RSMo.
We agree to precollect the Missouri motor fuel tax in accordance with Chapter 142 on all removals from a qualified terminal where we are a position
holder without regard to the license status of the person acquiring the fuel, the point or terms of the sale or the character of delivery.
We further agree to waive any defense that the State of Missouri lacks jurisdiction to require collection on all out-of-state sales by such person as to
which the person had knowledge that the shipments were destined for Missouri and that Missouri imposes the requirements under its general police
powers to regulate the movement of motor fuels.
Notice of Election must be signed by an authorized representative of the company as listed on page 2, Section 6 of the license application.
SIGNATURE OF OWNER, PARTNER, OR AUTHORIZED OFFICER
NAME OF PERSON SIGNING (PRINT OR TYPE NAME)
DATE
This publication is available upon request in alternative accessible format(s).
MO 860-0671 (11-2006)
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