Form Mf-169 - Application For Motor Vehicle Fuel And Special Fuel Producer/manufacturer, Blender, End Consumer
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1
2FOR OFFICE USE—LEAVE BLANK
KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
License No.
915 SW HARRISON ST.
Date License Issued
TOPEKA, KANSAS 66625-8000
Date Mailed
Phone Number: (785) 368-8222
Fax: (785) 296-4993
APPLICATION FOR MOTOR VEHICLE FUEL AND SPECIAL FUEL
PRODUCER/MANUFACTURER, BLENDER, END CONSUMER
1.
Name
2.
DBA Name
3.
Mailing address
Street Address or Post Office Box
City
State
Zip Code
4.
Location address
Street Address
City
County
State
Zip Code
5.
Federal Employers Identification Number
6.
Phone number (
)
Fax Number
(
)
7.
Check type of ownership:
Individual
Partnership
Corporation
Other
8.
List owner, partners, corporate officers and all stockholders who own 5% or more of company stock.
Social Security
Telephone
Name
Address
Title
Number
Number
9.
List the exact location(s) of each place applicant produces, refines, prepares, blends, distills, manufacturers, compounds, uses,
sells, or delivers motor vehicle fuels and /or special fuel in this state (location must be specific and correct). LIST ONLY PLACES
WHICH YOU OWN OR OPERATE AND FOR WHICH YOU ARE RESPONSIBLE. DO NOT LIST YOUR CUSTOMERS. DO NOT
LIST POST OFFICE BOX NUMBERS. List the exact location, use street numbers and legal description.
Address
City
County
Product(s) Produced,
Production Start Date
Manufactured, Blended
1.
2.
3.
10.
Do you transport your own products?
Yes
No If yes, please provide your Liquid Fuel Carriers License #
If no, who transports this product?
11. Contact person for tax return inquiries:
Name:
Phone Number:
Fax Number:
E-mail address:
12.
Are the applicant(s) at least 18 years of age?
Yes
No
13.
Are you or any partner, corporate officer or stockholder owning more than 5% of company stock, delinquent in payment of any
motor fuel taxes, interest or penalty, to a taxing agency in any state or to the federal government?
Yes
No
14.
Have you or any partner, corporate officer or stockholder owning more than 5% of company stock, been convicted of a felony
involving theft within 5 years immediately preceding the date of making application in this or any other jurisdiction?
Yes
No
15.
Have you or any partner, corporate officer or stockholder owning more than 5% of company stock, been convicted of a felony
Yes
No
involving fraud or tax evasion in this or any other jurisdiction?
16.
Have you or any partner, corporate officer or stockholder owning more than 5% of company stock, had a motor fuel license
revoked for cause in another state?
Yes
No
17.
Do you or any partner, corporate officer or stockholder owning more than 5% of company stock, intend to carry on the business
authorized by the license as agent of another?
Yes
No
18.
If you answered yes to any question 12-16, please explain on a separate sheet of paper.
(CONTINUED ON THE REVERSE SIDE)
MF-169
(Rev. 10/08)
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Parent category: Financial