Form Mf-627 - Cancellation Of License
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1Indiana Department of Revenue
Cancellation of License
MF-627
State Form 49115
(4-03)
Company Name:
DBA Name:
Address:
City:
State:
Zip Code
Please provide a license number for all license types you wish to cancel:
1.
Gasoline Distributor’s License Number:
2.
Oil Inspection Distributor’s License Number:
3.
Aviaiton Fuel Dealer’s Number:
4.
Marina Fuel Dealer’s Number:
5.
Special Fuel Importer’s License Number:
6.
Special Fuel Transporter’s License Number:
7.
Special Fuel Exporter’s License Number:
8.
Special Fuel Supplier’s License Number:
9.
Special Fuel Permissive Supplier’s License Number:
10. Special Fuel Terminal Operator’s License Number:
11. Special Fuel Blender’s License Number:
12. Special Fuel Dyed User’s License Number:
13. Special Fuel Eligible Purchaser’s License Number:
14. Petrolem Severance:
Signature:
Typed or Printed Name:
Title:
TID:
Date Signed:
Telephone Number
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Parent category: Financial