Form 04-407 - Qualified Dealer License Application/renewal (Page 4 of 4) in pdf

Form 04-407 - Qualified Dealer License Application/renewal Page 4

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QUALIFIED DEALER REPORTS

Check here if you would like to receive hard copy qualified dealer reports. Note that an up-to-date listing is available at all times on the Internet

I certify that an accurate record will be kept of all purchases, sales and uses of fuel, that the required monthly returns will be filed and tax will be

paid on or before the last day of the following calendar month. Under penalty of unsworn falsification, I declare that this application and any

attachments have been examined by me and to the best of my knowledge and belief are true, correct, and complete.

Signature of Applicant

Title

Date

NOTARY

Before me this day personally appeared the owner/operator to be known, and known by me to be the person(s) described in and who executed the foregoing

affidavit. WITNESS my hand and official seal at ___________________ in the State of _________________ this __________day of ______________, 2000.

Signature:________________________________________ Notary Public for:________________________ My Commission Expires:_____________

Examined by:

License Number Issued:

Form 04-407 (Rev 07/00)