Reset Form
MF 201
License number assigned
Rev. 7/10
P.O. Box 530
Columbus, OH 43216-0530
Application for License as a Motor Fuel Dealer
Pursuant to Ohio Revised Code section (R.C.) 5735.02, I/we hereby apply for a motor fuel dealer’s license. 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 busi-
ness 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 an Ohio charter # has been issued, use the name associated with that charter number.)
FEIN
SSN
Ohio charter number
Telephone
Fax
E-mail
2. Trade name/DBA if other than above
3. Reason for this license request:
New business
Purchased existing business (provide name, full address and
FEIN of the business you purchased)
Incorporated business
Other (list reason)
4. Are you involved as an owner, offi cer, partner or member with anyone else who holds an Ohio motor fuel dealer’s license?
Yes
No. If yes, provide the name, address and FEIN of the other dealer
5. Check whether applicant operates as:
Sole owner
Partnership
Corporation
LLC
LLP
Other (list)
6. If a corporation, date of qualifi cation
List name, address and SSN of all offi cers and directors (attach separate sheet, if necessary)
7. If a corporation, state name and address of statutory agent
8. If partnership, list name, address and SSN of all partners. If LLC or LLP, list name, address and SSN of all members.
9. Business address (P.O. boxes not acceptable)
10. Mailing address (if other than that shown on line 9)