Form Mf 204 - Application For License As A Motor Fuel Exporter Type A Or B
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MF 204
Rev. 3/00
License number assigned
P.O. Box 530
Columbus, OH 43216-0530
Application for License as a Motor Fuel Exporter Type A or B
Pursuant to Ohio Revised Code section (R.C.) 5735.026, I/we hereby apply for a license as a motor fuel exporter Type A
or B. For sole owner, print individual’s name, address, owner’s SSN and FEIN of the business. For a partnership, print full
name, address and SSN of all partners and the partnership’s FEIN. For an LLC or LLP, print the full name, address and SSN
of all members. For a corporation, print the corporate name, corporation charter number issued by the Secretary of State
authorizing business in Ohio and the corporation’s FEIN. Use a separate piece of paper if necessary.
Under penalties of prosecution, no person shall make a false
or fraudulent statement on this application.
1. Name of applicant
(If you are a corporation, DO NOT use your name, use the corporation name.)
FEIN
SSN
Telephone
Fax
E-mail
2. Trade name if other than above
Partnership
Corporation
LLC
LLP
3. Check whether applicant operates as:
Sole owner
Association
Other (list)
4. If a corporation, date of qualifi cation
List name, address and SSN of all corporate offi cers and directors
5. If a corporation, state name and address of statutory agent
6. If partnership, list name, address and SSN of all partners. If LLC or LLP, list name, address and SSN of all members.
7. Business address (P.O. boxes not acceptable)
8. Mailing address (if other than that shown on line 7)
9. Is your company owned or controlled by any other person or corporation?
Yes
No If yes, give name, address
and FEIN or SSN or the other person/corporation.
10. List the state or provinces to which you will export motor fuel. (Any future deletion or addition of states/provinces in
which you will export must be immediately reported in writing to the Motor Fuel Compliance Unit.)
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