Application For Permit To Mix, Blend And/or Distribute Alcohol-Gasoline Blends - Mississippi Department Of Agriculture And Commerce Page 2

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Source(s), supplier(s) of alcohol used by applicant in mixing, blending and/or distributing: (Names, addresses)
The undersigned applicant hereby certifies that all statements, information or schedules attached hereto are hereby made a part of this
application and that all statements and information contained herein are true and correct.
This the
date of
,
Full name of applicant
Firm name
NOTE: Application must be signed. If partnership, each must sign. If corporation, corporate name must be signed in full with the
officer’ s name or name of agent authorized to sign the application and title on lines below. Corporate seal must be impressed.
Corporate name
By
Title
By
Title
th
st
Permits expire on June 30
next after issue and application must be made on or before July 1
each year thereafter.
PPI No. 15
0500

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