Form Rt 132 - Application For Motor Fuel Distributor License - Nh Road Toll Bureau - Fy2010
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2STATE OF NEW HAMPSHIRE
FOR OFFICIAL USE ONLY
DEPARTMENT OF SAFETY
License No.: ______________
ROAD TOLL BUREAU
Date Issued: _____________
33 HAZEN DRIVE, CONCORD, NH 03305
By: ____________________
TELEPHONE: (603) 271-2311
Cancelled: _______________
TDD Access: Relay NH 1-800-735-2964
By: _____________________
-FY2010-
APPLICATION FOR MOTOR FUEL DISTRIBUTOR LICENSE
FEIN NUMBER: ______________________
SSN:_____________________________________
NAME: _____________________________________ TELEPHONE NO. _____________________
ADDRESS: _____________________________________________________________________
NO. AND STREET
CITY/TOWN
STATE
ZIP
CONTACT NAME:_________________________ EMAIL _________________________________
LOCATION WHERE RECORDS WILL BE AVAILABLE FOR AUDIT:
ADDRESS: ____________________________________________________________________
NO. AND STREET
CITY/TOWN
STATE
ZIP
NAMES, TITLES AND RESIDENT ADDRESSES OF PRINCIPAL OFFICERS:
NAME:
TITLE:
NUMBER & STREET:
CITY/TOWN:
STATE:
INDIVIDUAL
PARTNERSHIP
CORPORATION
COMPANY
OTHER ______________
(PLEASE COMPLETE THE REVERSE SIDE OF THIS APPLICATION)
↓ FOR OFFICIAL USE ONLY ↓
SECRETARY OF STATE_______________________ INSURANCE COMMISSIONER _______________________
DATE
BY
DATE
BY
BOND AMOUNT $____________ TYPE____________ EFFECTIVE ____________ CANCELLED _____________
RT 132 (REV 05/2009)
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