Application For Permit To Mix, Blend And/or Distribute Alcohol-Gasoline Blends - Mississippi Department Of Agriculture And Commerce

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No.
MISSISSIPPI DEPARTMENT OF AGRICULTURE AND COMMERCE
PETROLEUM PRODUCTS INSPECTION DIVISION
Post Office Box 1609
Jackson, Mississippi 39215-1609
601-359-1101
APPLICATION FOR PERMIT TO MIX, BLEND AND/OR DISTRIBUTE ALCOHOL-GASOLINE BLENDS
As required by regulation 10 adopted pursuant to Section 75-55-5 Mississippi Code of 1972 application is hereby made for a permit to
mix, blend and/or distribute alcohol-gasoline blends containing one percent or more of alcohol in the State of Mississippi.
Mixer/Blender/Distributor Name
Business or Trade Name
Mailing Address
City, State, Zip
Telephone Number
Fax Number
Is the business of the applicant owned by
individual
partnership
corporation
cooperative?
If partnership, name and address of all partners:
If corporation, state and date of incorporation:
Officers, name and address of all officers:
President
Vice President
Secretary
Treasurer
CEO
Principal office in State of Mississippi
How long has applicant been engaged in business for which application is made?
How many retail dealers does applicant serve in Mississippi? (attach list of business names and addresses)
Total gallons of alcohol/gasoline blends mixed, blended and/or distributed in Mississippi during the past twelve months:
Types of alcohol used by applicant in mixing blending and/or distributing:
,
,

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