Form R-5409 - Motor Fuel Excise Tax License Application Page 3
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4R-5409 (7/06)
K. Distributor Information
If you are applying for a distributor’s license, you must complete this section.
1. Will you import motor fuel into Louisiana from a permissive supplier?
❐
Yes
If yes, you must complete Section M – Importer Information.
❐
No
2. Will you export motor fuel from Louisiana?
❐
Yes
If yes, you must complete Section L – Exporter Information.
❐
No
3. Will you purchase motor fuel for resell from a supplier or another distributor?
❐
Yes
❐
No
4. Will you resell motor fuel to another licensed distributor or bulk consumer?
❐
Yes
❐
No
5. Will you resell motor fuel to a retail dealer?
❐
Yes
❐
No
6. Will you resell motor fuel to a consumer?
❐
Yes
❐
No
L. Exporter Information (Attach additional pages if necessary.)
If you plan to export motor fuel from Louisiana, you must complete this section.
1. What mode of transportation will you use to export from Louisiana? (Check all applicable boxes.)
❐
❐
❐
mlkjdf;lajksdf;lakdjsf
Transport Vehicle
Railroad Tank Car
Other_____________________________________________________
2. Will you purchase motor fuel from a licensed supplier and/or distributor?
❐
Yes
❐
No
3. Will you export motor fuel from a bulk plant?
❐
Yes
❐
No
4. List the state(s) to which you plan to export motor fuel and your License or Registration Number for each state.
State
License/Registration Number
State
License/Registration Number
State
License/Registration Number
lkj;alkdfj;aljksdf
1.
65
3.
lk
;ljl;kj
5.
l;
lj
2.
lj
4.
l;
;lk
6.
;l
M. Importer Information (Attach additional pages if necessary.)
If you plan to import motor fuel into Louisiana, you must complete this section.
1. Will you import motor fuel that you receive from a permissive supplier?
❐
Yes
❐
No
2. What mode of transportation will you use to import into Louisiana? (Check all applicable boxes.)
❐
❐
❐
hsdklfhaldjksfy
Transport Vehicle
Railroad Tank Car
Other_____________________________________________________
3. Do you plan to import motor fuel from a bulk plant located in another state?
❐
Yes
❐
No
4. List the state(s) from which you plan to import motor fuel and your License or Registration Number for each state.
State
License/Registration Number
State
License/Registration Number
State
License/Registration Number
654654
1.
65
3.
65
65464
5.
64
65
88
44
2.
4.
6.
N. Motor Fuel Transporter Information
If you plan to transport motor fuel, you must complete this section.
1. Will you transport motor fuel? (Check all the boxes that apply.)
❐
❐
❐
For import into Louisiana
For export from Louisiana
From point to point within Louisiana
2. What mode of transportation will you use? (Check all applicable boxes.)
❐
❐
❐
❐
Marine Vessel
Transport Vehicle
Railroad Tank Car
Other____________________________
Page 3
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