Form Reg-8-A - Motor Fuel And Other Fuel Information (Distributor, Supplier, Receiver, Or Blender)

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Illinois Department of Revenue
_____________
REG-8-A
Motor Fuel and Other Fuel Information
License issued
_____________
(Distributor, Supplier, Receiver, or Blender)
License number
Do not write above this line.
Step 1: Application information
Tell us if you are applying for a license as a
distributor
,
supplier
,
and/or receiver
.
Tell us if you are applying for a permit to blend. Yes
No
Federal Employer Identification Number (FEIN) ______ - __________________
Illinois Business Tax number (IBT)
____________ - ____________
Step 2: Identify your company (All information must be provided completely and accurately)
________________________________________________________
___________________________________________________
Business name
Attention
________________________________________________________
___________________________________________________
Doing business as (DBA) if applicable
Mailing Address (number and street)
________________________________________________________
___________________________________________________
Principal place of business (number and street)
City
State
ZIP
________________________________________________________
City
State
ZIP
________________________________________________________
___________________________________________________
County
Telephone
Illinois agent (if out-of-state applicant) name (See instructions)
________________________________________________________
___________________________________________________
Location of books and records (number and street)
Mailing address (number and street)
________________________________________________________
___________________________________________________
City
State
ZIP
City
State
ZIP
Step 3: Complete the following ownership information
1
Ownership type:
sole proprietor
partnership
corporation
other
__________
(specify)
2 Provide the following information for the sole-owner, all partners, or the president, vice-president,
secretary and treasurer of the corporation. Attach additional sheets if necessary.
Name
____________________
____________________
____________________
____________________
Title
____________________
____________________
____________________
____________________
Home address
____________________
____________________
____________________
____________________
City, state, ZIP
____________________
____________________
____________________
____________________
SSN
____________________
____________________
____________________
____________________
Date of birth
____________________
____________________
____________________
____________________
3
State in which incorporated
___________________________ Date of incorporation ______ / ______ / ____________
4
If you are an out-of-state company, are you registered in Illinois as a foreign corporation? Yes
No
If no, you must contact the Illinois Secretary of State to determine if you must register as a foreign corporation.
Step 4: Tell us about your business
5
If you are an out-of-state company, will you sell motor fuel or other fuel in Illinois? Yes
No
• Motor fuel is defined as all volatile and inflammable liquids produced, blended, or compounded for the purpose of, or which are suitable
or practicable for, operating motor vehicles; motor fuel includes special fuel.
• Special fuel refers to all volatile and inflammable liquids capable of being used for the generation of power in an internal combustion
engine, except that it does not include gasoline or combustible gases. Special fuel includes diesel fuel.
• Fuel is defined as all liquids defined as motor fuel and aviation fuels and kerosene, but excluding liquified petroleum gases.
6 Tell us below if you are now or have ever been associated with any other corporation, company, or individual which has or had an interest
in the sale or distribution of motor fuel/other fuels. If you are a corporation or partnership, tell us whether any officer, director, or partner
was ever associated with any corporation, partnership, or individual which has had interest in the sale of motor fuel/other fuels.
If not applicable, check this box.
Name of individual
_______________________________________________________________________________
Name of business
_______________________________________________________________________________
Motor Fuel License number
________________________
FEIN ______ - __________________
SSN
_________ - ______ - ____________
Page 1
REG-8-A (R-03/13)

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