Form Mfa-1 - Combined Motor Fuels License Application Page 6
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11An Application Fee of $150 is due for a 3-year license.
Retailer of Motor Fuels
You must file a separate MFA-1 for each retail establishment.
1.
You engage in the business of selling or dispensing motor fuel to the consumers in this state.
2.
You operate a blocked pump for clear kerosene.
3.
You sell Aviation Fuels to the consumers.
4.
You dispense LPG into on-road vehicles.
Please provide the following regarding your retail location.
1. Do you have a generator on site?
Yes
No If yes please submit a description.
2. Will your generator power all of your pumps?
Yes
No
3. Is your generator hard wired?
Yes
No
4. Is your station pre-wired for a generator?
Yes
No
5. Number of gasoline pumps. _______________ Number of diesel/kerosene pumps. _______________
6. Average monthly gallons of gasoline sold during the last 12 months. ________________
7. Average monthly gallons of diesel fuel sold during the last 12 months. _______________
8. Do you lease your retail location (if yes, please provide a copy of the lease agreement)?
Yes
No
An Application Fee of $50 is due for a 1-year license for each
Transporter
conveyance licensed.
1.
You transport your own fuels.
2.
You transport fuels under contract as a common carrier. (List your customers, each customer’s license number, and the fuels transported).
For each Fuel Transportation Vehicle or Vessel, give the following information. (Attach rider if you are licensing more than 14 vehicles or vessels).
Conveyance Type
VIN or Vessel Name
Conveyance Type
VIN or Vessel Name
Total Application Fee due for this application: $________
Section 9 – Consumer Registration
Only consumers may complete this section. If you sell fuel, then you are not a consumer and you must apply for one of the
licenses in Section 8.
You purchase dyed fuel for use in on-road vehicles.
You blend your own fuel.
Check all that
You pick up taxable, on-road fuel from a terminal.
You recycle fuel for use on-road.
apply.
You make your own fuel.
You acquire taxable fuel that has not been taxed.
Gasoline or
Diesel, Biodiesel
Dyed Diesel, Biodiesel or
Aviation Fuel
Check each type of fuel you will consume.
Ethanol
or Kerosene
Kerosene
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