Fillable Form 795 - Missouri Motor Fuel Tax License Application

FORM 795, MISSOURI MOTOR FUEL TAX LICENSE APPLICATION

Do not write in the shaded block. It is for department use only.

Type of Application

Place a check mark in the appropriate box. If you already have a Missouri fuel tax number and wish to make changes or

have your license reinstated, please provide license number in the space provided.

MITS No. (Missouri Tax I.D. Number)

If you have an 8-digit Missouri Tax I.D. Number (MITS Number), enter that number in the space provided, otherwise

leave blank.

IRS 637 Number (Number issued by IRS for various excise tax activities)

If you have an IRS 637 Number, enter that number in the space provided. If you do not have an IRS 637 number, leave

blank.

FEIN

Enter the Federal Employer Identification Number issued to your company by the Federal Government. If you do not

have a FEIN number, leave blank.

Section 1 — Business Name and Location

Enter your business name, DBA, physical location of business, mailing address, address where books and records are

kept, county, fax number, telephone number, if you have internet access and/or a web page, your email address and the

name of a contact person for questions concerning the application. Please indicate how you would like to receive reports

and updates. Check the corresponding box if you would like to download forms from the internet, if you wish to have

paper copies sent to you or if you would like an e-mail reminder each month when reports or due.

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 release information to the accounting firm. If someone other than an officer of the company signs

the applications 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.

Section 3 — Type of Activity

For each activity you plan to conduct in Missouri, place a check mark in the appropriate box and provide the requested

information.

Please indicate the effective date for your license for each activity type you are applying for. This date should not be

before the issue date of the bond you will be posting.

Section 4 — Product Types

For each type of motor fuel you plan to handle, place a check mark in the appropriate box. If a product is not listed, check

the box marked "other" and list the name of the product(s).

Section 5 — Type of Ownership

Place a check mark in the box that describes the ownership structure of your business and provide the required informa-

tion.

If your company is not in compliance with the Missouri Secretary of State’s office, you will need to contact them in order to

determine if you need to be registered. You may reach them by telephone at (573) 751-3827 or visit their web site at

If your company does not meet their requirements to register, please remit a letter along with

your application stating the reason for exemption.

Section 6 — Ownership Information

Provide the requested information for the owners, partners, members or officers of the business.

Section 7 — Provide the requested information only if you purchased an existing business.

Section 8 — Previous Motor Fuel Experience

Provide the requested information for any owner, officer, or employee who presently or previously, owned, operated or

managed another motor fuel company.

Section 9 — Fuel Suppliers/Customers

Complete this section as follows:

Suppliers — List from whom you receive fuel, phone number, Federal I.D. Number, License Number, product

type, Terminal Number where product is received, how received. (Example: ABC Refinery, 555-555-5555, 44-

4444444, S0000, gas, T-43-MO-3700, Pipeline)

Form 795 - Missouri Motor Fuel Tax License Application - 2006 Page 6

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