Form Gt-1 - Gasoline License Application
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1
2Rev. 5/12
Massachusetts
Form GT-1
Department of
Gasoline License Application
Revenue
Check all that apply:
Distributor
Unclassified importer
Unclassified exporter
This application is for licenses beginning calendar year 2012. The undersigned hereby makes application under the provisions of M.G.L. Ch. 64A and
62C, as amended, for a license of the type checked above and for the calendar year stated below.
Name
Year
Identification number
Type of identification number (check one):
Federal Identification number
Social Security number
Other:
Street address of principal place of business
City/Town
State
Zip
Address where records are maintained (if different from above)
Telephone
Type of organization (check one):
Corporation
Partnership
Individual
Other:
If a corporation, enter state in which incorporated
Date incorporated
Name of treasurer
Name of president
Declaration
Pursuant to M.G.L. Ch. 62C, sec. 19A, I certify under the penalties of perjury that, to the best of my knowledge and belief, I have filed all state
tax returns and paid all state taxes required under law.
Signature
Date
Name of organization
Authorized agent
Complete reverse side. Fee of $100 per license must accompany application. Make check payable to Commonwealth of Massachusetts.
Mail to: Massachusetts Department of Revenue, PO Box 7012, Boston, MA 02204.
printed on recycled paper
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