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Michigan Department of Treasury
3712 (Rev. 09-13)
This form issued under authority of P.A. 403 of
2000, as amended. Filing is mandatory.
Motor Fuel Tax License Application
Failure to provide all information will
delay the processing of your application.
PART 1: IDENTIFYING INFORMATION
If a corporation or LLC, State of Incorporation
1. Type of Ownership:
Individual
Partnership
Other:
Date Incorporated
Domestic Corporation
Foreign Corporation
Trust/Estate
LLC (Limited Liability Corporation)
Corporate or LLC Number (if applicable)
S. Corporation
LLP (Limited Liability Partnership)
3. Federal Employer Identification Number (FEIN), TR, or ME Number
2. Legal Name
4. Trade Name (DBA)
5. Business Telephone Number
6. Business Fax Number
7. Legal Address (Street, PO Box, City, State, ZIP)
8. Mailing Address (Street, PO Box, City, State, ZIP)
9. Physical Location of Business (Not PO Box)
10. Licensing Conact
11. Tax Preparer Contact
(name, telephone no., fax no., email)
(name, telephone no., fax no., email)
PART 2: OWNERSHIP INFORMATION
Lines 12-14 must be completed for each corporate officer, principal, partner or owner. Attach additional sheet(s) if necessary.
B.
C.
D.
E.
A.
Full Name
Residence Address
Residence
Social
Title
(first, middle, last)
(Street, City, State, ZIP)
Telephone Number
Security Number
12.
13.
14.
15. Foreign Corporations: Name and Complete Address of Resident Agent
FEIN of Resident Agent
Telephone Number of Resident Agent
16. Date Motor Fuel Operations began in Michigan
17. Anticipated effective date of license(s) (MM/DD/YYY)
18. This form must be signed by the owner, two partners or two corporate officers responsible for filing returns and making tax payments. I declare under
penalty of perjury, that I have examined this application, including accompanying schedules and statements, and to the best of my knowledge, it is true
and complete.
Signature
Printed Name
Title
Date
Signature
Printed Name
Title
Date
19a. License Type
19b. License Fee
Mail completed applications to:
Michigan Department of Treasury
Special Taxes Division
PO Box 30474
Lansing, MI 48909-7974
TREASURY USE ONLY