Form 3712 - Motor Fuel Tax License Application Page 2
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83712, Page 2
20. Do you hold a Federal 637 registration under section 4101 of the Internal Revenue Act?
Yes
No
If yes, enter your Federal 637 number and activity letter (attach a copy of your registration letter):
21. Has the corporation, LLC, LLP, partnership, or any officers, members,
22. Has the corporation, LLC, LLP, partnership, or any officers, members,
controlling shareholders of the corporation or owners of the business
controlling shareholders of the corporation or owners of the business had
a motor fuel license revoked or refused for issuance or renewal in the
been convicted of any felony or misdemeanor involving motor fuel or any
tax issues?
State of Michigan or another state or foreign jurisdiction?
Yes
No
Yes
No
If yes, explain:
If yes, explain:
23a. Has the corporation, LLC, LLP, partnership, or any officers,
23b. Has the corporation, LLC, LLP, partnership, or any officers,
members, controlling shareholders of the corporation or owners of the
members, controlling shareholders of the corporation or owners of the
business been licensed in another name in Michigan?
business been licensed in another state?
Yes
No
Yes
No
Account Number (FEIN, TR, ME):
State:
Account Number (FEIN, TR, ME):
PART 3: STORAGE/INVENTORY
24. Will you maintain bulk fuel storage facilities that are not part of a
Yes
No
If Yes
Owned?
Leased?
federally registered terminal or refinery?
Total Fuel
Gasoline
Clear Diesel
Dyed Diesel
Unblended Biodiesel
Unblended
Storage in
(including
(including
(including
Aviation Fuel
(B100)
Ethanol
Gallons:
Ethanol blend)
Biodiesel blend)
Biodiesel blend)
In Michigan
Outside Michigan
Address and storage capacity for each storage location (Attach additional sheet(s) if necessary).
Receipts
25. From whom will you purchase fuel and which fuel types will you purchase? List below all companies by name, federal identification number,
location, and product codes, including dyed diesel (Attach additional sheet(s) if necessary).
Name
FEIN
Location (City, State/Province, Country)
Product Code
Disbursements
26. Will you sell dyed diesel fuel for taxable purposes?
Yes
No
If yes, identify purchaser and explain:
Company Name
FEIN
Address
City, State, ZIP
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