Form Mf 203 - Application For License As A Retail Motor Fuel Dealer Page 2
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2MF 203
Rev. 12/08
Page 2
11. Do you take “stick readings” of fuel at your retail location?
Yes
No If yes, how long are records kept?
Do you take meter or totalizer readings at your retail location?
Yes
No If yes, how often?
12. Have you, any partner, member or a corporation in which you or any other partner or member had greater than 5%
interest ever had a retail motor fuel dealer’s license revoked by any state, federal government or province?
Yes
No If yes, provide the state, etc., the reason for revocation and the date or revocation.
It is understood that upon approval of this application, the applicant will comply with all of the laws/requirements as applicable
under Ohio Revised Code Chapter 5735. Failure to comply with applicable law could result in revocation of license, assessment
of tax and penalties, and possible criminal prosecution.
Signature of dealer or offi cer of company
Title
Date
Sworn to before me and in my presence subscribed this
day of
20
.
Notary public
Return completed application to the Ohio Department of Taxation, Motor Fuel Tax Refund Unit, P.O. Box 530, Columbus, OH
43216-0530. Retain copy for your fi les. Direct any questions to (855) 466-3921 or fax (614) 752-8644.
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