Form Mft-4a - Application For Importer'S License - 2000
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2MFT-4A
STATE OF NEW JERSEY
(02-00, R-2)
DIVISION OF TAXATION
MOTOR FUEL TAX
Application Required by
PO BOX 189
NJ Motor Fuel Tax Law
Trenton, New Jersey 08695-0189
APPLICATION FOR IMPORTER’S LICENSE
Application is hereby made by the undersigned for a Importer’s License to operate in the State of New Jersey in compliance with Chapter 39 of Title 54,
Taxation, of the Revised Statutes and the Acts amendatory thereof and supplemental thereto. This license is for a period of three (3) years. A payment of
the fee of $450.00 must accompany this application. Every Importer’s License is subject to the filing of a bond in such form and amount as provided by law.
Make check or money order payable to: STATE OF NEW JERSEY-MFT.
1. FID #
-
OR Soc. Sec. # of Owner
-
-
2. Name ________________________________________________________________________________________________________________
(IF INCORPORATED - give Corp. Name; IF NOT - give Last name, First Name, MI of Owner(s))
3. Trade Name ___________________________________________________________________________________________________________
5. Mailing Name and Address - (if different from business address)
4. Business Location:
Street _____________________________________________________
Name________________________________________________
City_________________________________________ State
Street________________________________________________
-
Zip Code
City____________________________________ State
(Give 9-digit Zip)
-
Zip Code
(Give 9-digit Zip)
6. Beginning Date for this business in New Jersey
__________ / __________ / __________
Month
Day
Year
7. Type of Ownership (check one):
¨
¨
¨
¨
¨
NJ Corporation
Sole Proprietor
Partnership
Out-of-State Corporation
Limited Partnership
¨
Other - explain _________________________________________________________________________________________________________
8. Telephone Numbers: Contact Person ______________________________________________
Title _____________________________________
Daytime: (
) _________ - _________________Ext___________
Evening: (
) _________ - _________________Ext__________
9. IF A CORPORATION, complete the following:
Date of Incorp. __________ / __________ / __________
State of Incorp.
Month
Day
Year
10. Provide the following information for ALL owners, partners or responsible corporate officers. (If more space is needed, attach rider).
%
NAME
SOCIAL SECURITY NUMBER
HOME ADDRESS
(Last Name, First, M.I.)
OWNED
TITLE
(Street, City, Zip)
NOTE: On a separate sheet of paper provide the name of stockholders owing 10% or more of the outstanding shares of stock in the corporation.
n
11. List parent company, wholly owned subsidiaries, and/or any affiliates_________________________________________________________________
________________________________________________________________________________________________________________________
12. Give name, title, and telephone number of person charged with the duty of filing motor fuels tax reports and location where reports are prepared and
records kept ______________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
13. Give name, title and address of agent in New Jersey or registered New Jersey agent on whom service may be made (must be documented by letter from
agent) ___________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
NOTE: Question 13 must be completed by out-of-state businesses
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