Form 795 - Missouri Motor Fuel Tax License Application Page 3
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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
DOR USE ONLY — LICENSE NUMBERS
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
FORM
SUPPLIER/PERMISSIVE SUPPLIER _____________________________
(573) 751-2611
TDD 1-800-735-2966
DISTRIBUTOR _______________________________________________
795
MISSOURI MOTOR FUEL TAX LICENSE
TRANSPORTER _____________________________________________
APPLICATION
(REV. 11-2011)
TERMINAL OPERATOR _______________________________________
E-mail: excise@dor.mo.gov Fax: (573) 522-1720
ELIGIBLE PURCHASER
YES
NO
LIST LICENSE NUMBER IF MAKING A CHANGE
NEW APPLICATION
CHANGE
REINSTATEMENT
OR REQUESTING REINSTATEMENT:
SECTION 1 — BUSINESS NAME AND LOCATION
MO TAX I.D. NUMBER
IRS 637 NUMBER
FEDERAL I.D. NUMBER
DO YOU HAVE INTERNET ACCESS?
YES
NO
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __
BUSINESS NAME
INTERNET SITE ADDRESS (WEB PAGE)
DBA NAME
E-MAIL ADDRESS
It is not necessary to type hyphens or parentheses.
PHYSICAL LOCATION OF BUSINESS
CITY, STATE, ZIP CODE
COUNTY
TELEPHONE
(_ _ _) _ _ _ - _ _ _ _
BUSINESS MAILING ADDRESS
CITY, STATE, ZIP CODE
COUNTY
FAX
(_ _ _) _ _ _ - _ _ _ _
BOOKS AND RECORDS ADDRESS
CITY, STATE, ZIP CODE
COUNTY
NAME OF CONTACT PERSON
HOW DO YOU WANT TO RECEIVE REPORTING FORMS AND UPDATES?
I will download from the Internet.
(CHECK ONE)
Please mail forms on a yearly basis.
SECTION 2 — CONTACT PERSONS
Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax information can
only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant access to your tax informa-
It is not necessary to type hyphens or parentheses.
tion, you must supply us with a power of attorney giving us the authority to release confidential information to them.
CONTACT PERSON
FOR REGISTRATION
_________________________________________________
TELEPHONE NUMBER ___________________________
E-MAIL ADDRESS ___________________________
CONTACT PERSON
REPORTING
_________________________________________________
TELEPHONE NUMBER ___________________________
E-MAIL ADDRESS ___________________________
SECTION 3 — TYPE OF ACTIVITY — CHECK ALL THAT APPLY
Enter dates as mm/dd/yyyy.
SUPPLIER/POSITION HOLDER IN A MISSOURI TERMINAL (OWNS PRODUCT IN THE TERMINAL FOR SALE OR EXCHANGE)
EXPORT FUEL FROM MISSOURI
LIST STATE(S) AND LICENSE NUMBER(S)
______________________________________________________________________________
PARTICIPATE IN EXCHANGES
LIST EXCHANGE PARTNERS
______________________________________________________________________________
EFFECTIVE DATE FOR LICENSE
___________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 16
PERMISSIVE SUPPLIER/POSITION HOLDER IN AN OUT-OF-STATE TERMINAL (OUT-OF-STATE SUPPLIER THAT ELECTS TO HAVE A SUPPLIER’S LICENSE)
EFFECTIVE DATE FOR LICENSE
___________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 13, 15 AND 16
TERMINAL OPERATOR/OPERATING A MISSOURI TERMINAL (OWNS, OPERATES OR CONTROLS A TERMINAL)
TYPE OF TERMINAL
BARGE
PIPELINE
DO YOU COMMINGLE PRODUCTS WITH THOSE OF ANY OTHER COMPANY?
YES
NO
IF YES, LIST COMPANY NAME(S) ________________________________________________
EFFECTIVE DATE FOR LICENSE
___________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 9, 12, 15 AND 16
DISTRIBUTOR (IMPORTS, EXPORTS OR BLENDS MOTOR FUEL AND MAY QUALIFY AS AN ELIGIBLE PURCHASER AUTHORIZED TO PURCHASE ON A TAX DEFERRED BASIS)
IMPORTS — LIST NAME OF STATE(S) AND LICENSE NUMBER(S) __________________________________________________________________________________________________________
EXPORTS — LIST NAME OF STATE(S) AND LICENSE NUMBER(S) _________________________________________________________________________________________________________
BLENDS — LIST TYPES OF FUELS BLENDED ___________________________________________________________________________________________________________________________
MY COMPANY WISHES TO QUALIFY FOR “ELIGIBLE PURCHASER” STATUS AS PROVIDED FOR UNDER SECTION 142.848, RSMo, TO PURCHASE FUEL ON A TAX DEFERRED BASIS.
EFFECTIVE DATE FOR LICENSE
___________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 11 AND 14 THROUGH 16
TRANSPORTER (OPERATES A PIPELINE, BARGE, RAILROAD OR TRANSPORT TRUCK TRANSPORTING FUEL IN MISSOURI)
DO YOU TRANSPORT FUEL FOR HIRE IN MISSOURI?
YES
NO
EFFECTIVE DATE FOR LICENSE
___________________________________________________________________________________________________________________
COMPLETE SECTIONS 1 THROUGH 11, 15 AND 16
SECTION 4 — TYPE OF PRODUCT — CHECK ALL THAT APPLY
GASOLINE
GASOHOL
ALCOHOL
AVIATION GASOLINE
JET FUEL
UNDYED DIESEL FUEL
DYED DIESEL FUEL
UNDYED KEROSENE
DYED KEROSENE
ETHANOL
BIODIESEL
DYED BIODIESEL
OTHER _____________________________________
DOR-795 (11-2011)
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