Form Wv/mft-App - West Virginia Motor Fuel Excise Tax License Application

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West Virginia
West Virginia Motor Fuel Excise Tax
WV/MFT-APP
State Tax
License Application
Rev. 10/13
Department
Please read instructions prior to completing application.
PLEAsE PrinT in ink or TyPE.
A
A
i
pplicAnt
nformAtion
Legal Business or Corporation Name
FEIN/SSN
Trade Name or DBA (if different from Business Name)
Federal Certificate of Registry Number
Contact Person
Telephone Number
Fax Number
E-mail Address
(
)
(
)
B
A
i
ddress
nformAtion
Physical Location (do not list P.O. Box)
City
State
Zip Code
Mailing Address (if different from above)
City
State
Zip Code
Address for Business Records
City
State
Zip Code
C
l
i
icense
nformAtion
(Attach additional pages if necessary.)
Check each license for which you are applying
 Supplier/Refiner
 Importer
 Terminal Operator
 Motor Fuel Transporter
 Permissive Supplier
 Exporter
 Blender
 Distributor
 Alternative Fuel Bulk End User
 Producer/Manufacturer
 Provider of Alternative Fuel
 Retailer of Alternative Fuel
List business license number(s) for the following (if applicable)
IRP
WV MCRT
IFTA
License number:
License number:
License number:
Enter 5-digit Control Number assigned by the Secretary of State's Office, if applicable
You must have a control number to submit this application, except for sole proprietorship or general partnership.
D
t
B
o
ype of
usiness
wnership
Check each license for which you are applying
 Sole-Owner
 General Partnership
 Joint Venture
 Other (specify below)
 Domestic Corporation
 Limited Partnership
 Association
 Foreign Corporation
 Limited Liability Partnership
 Limited Liability Company
___________________________
Corporation: provide all corporate officers. partnership: provide all partners. sole proprietorship: provide owner.
all others: provide all general partners, members, or managers. (Attach additional pages if necessary.)
Full Legal Name
Title
Social Security Number
Home Address
City
State
Zip Code
Full Legal Name
Title
Social Security Number
Home Address
City
State
Zip Code
If your business organization is a partnership, sole proprietorship, or your business is based in another state you must provide an agent for service of process.
If you are applying for an Exporter's License, you must provide a West Virginia registered agent.
Name
Address
City
State
Zip Code
Telephone Number
E-mail address
(
)
Fax Number
(
)
*o58071301W*
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