Form Crf-007 - Completion Of The Motor Fuel Distributor Application - 2013 Page 2

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CRF-007 (Rev. 9/13)

GEORGIA DEPARTMENT OF REVENUE

TAXPAYER SERVICES DIVISION

PO BOX 49512

OFFICE USE ONLY

ATLANTA, GA 30359-1512

1-877-423-6711 TSD-motor-fuel-lic@dor.ga.gov

TOTAL AMT RECEIVED

MOTOR FUEL DISTRIBUTOR APPLICATION

DISTRIBUTOR LICENSE NO.

R (

I T

)

(Form CRF-002 must be completed before license can be issued)

STATE TAXPAYER IDENTIFIER

GEORGIA SALES TAX NUMBER

FEIN (FEDERAL IDENTIFIER NUMBER)

LEGAL BUSINESS NAME

TELEPHONE NUMBER

E-MAIL ADDRESS

LOCATION ADDRESS

CITY

STATE ZIP CODE

FOR WHICH TYPE OF DISTRIBUTOR LICENSE ARE YOU APPYLING FOR?

[ ] MOTOR FUELS, INCLUDING GASOLINE. *Must be Importing and Exporting

[ ] LP (LIQUID PROPANE)

[ ] MOTOR FUELS, EXCLUDING GASOLINE. *Please specify JET FUEL.

[ ] AVIATION G

ASOLINE

[ ] SPECIAL FUELS

WHEN DID OR WILL YOU START

DISTRIBUTING OR USING MOTOR FUELS?

TYPE OF BUSINESS

[ ] RESELLER

[ ] DUAL USER (Does not include Fuel Oils)

GEORGIA ANTICIPATED MONTHLY SALES IN GALLONS

RETAIL

WHOLESALE

FUEL TYPE

Taxable

Non-Taxable

Taxable

Non-Taxable

GASOLINE

FUEL OILS

JET FUEL

LP GAS

SPECIAL FUELS

AVIATION GASOLINE

* Not Including Jet Fuels *

DO YOU SELL TO CONSUMERS THAT HAVE TAXABLE USE OF THESE FUELS?

[

] FUEL OILS

[ ] LP GAS

[ ] SPECIAL FUELS

[ ] YES

[ ] NO

ANTICIPATED MONTHLY IMPORTS AND EXPORTS IN GALLONS

FUEL TYPE

IMPORTS

EXPORTS

GASOLINE

FUEL OILS

JET FUEL

LP GAS

SPECIAL FUELS

AVIATION GASOLINE

* Not Including Jet Fuels *

FOR SALES TO US GOVERNMENT, LIST

VENDOR ACCOUNT NUMBER (If applicable)

WILL YOU BE EXPORTING ALL YOUR GASOLINE

SPECIFY THE STATE IN WHICH TITLE

PURCHASES?

[ ] YES

[ ] NO

OF FUEL WILL TRANSFER TO YOU

ANTICIPATED MONTHLY USE IN GALLONS (Highway and Non-Highway Use)

FUEL TYPES

HIGHWAY

NON-HIGHWAY

FUEL OILS

LP GAS

JET FUEL

SPECIAL FUELS

ANTICIPATED MONTHLY USE IN GALLONS OF AVIATION GASOLINE

THIS APPLICATION HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE IT IS TRUE AND CORRECT .

___________________________________________________

______________________________________________

__________________________

Signature

Title

Date

STAMPED SIGNATURE NOT ACCECPTABLE)

(Must be signed by owner, partner, or authorized officer of corporation -

DEFINITIONS: FUEL OILS: Diesel No 1 and 2- Heating No. 1 and 2- Jet A and Tractor Fuel (Kerosene Based)

LP: Liquid Propane, Butane, Propylene, and/or Butylenes.

SPECIAL FUELS: All other sources of energy other than gasoline, fuel oil or liquid propane gas (LP). CNG & Bio Diesel should be included. HIGH-

WAYS: That portion or right of way open to the public as a matter of right for vehicular travel even though under (re)construction maintenance or repair.

TAXABLE USE OR SALE: Fuel used to propel a vehicle upon the public, Fuel used or consumed in or upon a vehicle that is designed for use and is used

upon the public highways, and/or Fuel for construction, maintenance, repair or reconstruction of public highways.