Form Wv/mft-App - West Virginia Motor Fuel Excise Tax License Application Page 4
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i
ervice
tAtion
etAil
utlet
nformAtion
(Attach additional pages if necessary.)
If you plan to own or lease an alternative fuel and/or motor fuel commercial refueling facility in West Virginia, you must complete this section.
oWn
Product
Storage Capacity
WV ID Number
Physical Location (Street Address)
City
Code
(gallons)
lease
Product
Storage Capacity
WV ID Number
Physical Location (Street Address)
City
Code
(gallons)
Q
B
r
onding
equirements
(Check One)
1. Surety bond
2. Proof of financial responsibility
3. 18 months good filing status in lieu of 1 or 2
R
t
p
-c
A
Ax
re
ollection
greement
Permissive Suppliers must complete this section.
I agree to collect the taxes due to the State of West Virginia on Motor Fuel that has West Virginia as its destination state and that was removed from a terminal located in another state
Authorized Representative's Name (Please print or type)
Title
Authorized Representative's Signature
Date
Telephone Number
Fax Number
E-mail Address
(
)
(
)
S
c
►►► A
'
.
ertificAtion
ll ApplicAnt
s must complete this section
I CERTIFY THAT I HAVE READ THIS APPLICATION AND KNOW AND UNDERSTAND ITS CONTENTS AND THAT ALL THE INFORMATION HEREIN IS TRUE AND ACCURATE. I
UNDERSTAND IT IS UNLAWFUL TO KNOWINGLY MAKE A FALSE STATEMENT ON THE APPLICATION AND THAT ANY VIOLATION MAY BE PROSECUTED.
Authorized Representative's Name (Please print or type)
Title
Authorized Representative's Signature
Date
Telephone Number
Fax Number
E-mail Address
(
)
(
)
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