Form Tdd - Application For Export Permit Certificate - State Of Rhode Island

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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Revenue
DIVISION OF TAXATION
Excise Tax Section
One Capitol Hill
Providence, RI 02908-5800
Fax:
(401) 574-8914
Office: (401) 574-8813
APPLICATION FOR EXPORT PERMIT CERTIFICATE
Application is hereby made for registration as an Exporter of Motor Fuels from the State of
Rhode Island in accordance with the provisions of Chapter 36 of Title 31, General Laws, 1956, as
amended.
Name of Applicant_____________________________________________________
(name of business, corporation, or owner license is to be issued to)
Home office address _____________________________________________________
City/Town______________________________
State ________ Zip Code________
State if Individual or Partnership __________________________________________________
Name & address of each owner:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
State where incorporated _________________________________________________
If corporation, provide names & addresses of officers (listed below):
OFFICERS
NAME
ADDRESS
President
Vice President
Secretary
Treasurer
Distribution area with supplier covered in your contract___________________________
Type of motor fuel to be exported ____________________________________________
Estimate of anticipated average monthly gallonage to be exported _________________
The undersigned hereby certifies that the information stated on this form is true, correct, and
complete to the best of his/her knowledge and belief.
Date _______________________
Name________________________________________
By __________________________________________
Official position _______________________________
TDD (401) 574-8934 (Telecommunication Device for the Deaf)
September 2011

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