Form Dmf-5 - Application For Change Of Designation
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1Division Use Only — DLN Stamp
Division Use Only — Date Stamp
Send to:
Division of Taxation
PO Box 189
Pursuant to NJSA 54:39-101 et seq
Trenton, NJ 08695-0189
10-2010
Application for Change of Designation
Form DMF-5
Licensee Information
Name
Tax ID Number
Address
Contact person
Phone Number
Position
Change Desired
Current Designation(s)
Desired Designation(s)
AvFuel Dealer
AvFuel Dealer
Wholesaler
Wholesaler
Importer
Importer
Exporter
Exporter
Blender
Blender
Attach a list of potential customers including their names, address, points of delivery,
tax ID numbers, and the products to be sold to each. Also attach a list of suppliers,
including their names, pick up locations, tax ID numbers, and the products to be
purchased from each.
Affirmation
By signing, the signatory affirms that the
information on this form, including the
attachments, is accurate and complete.
Incomplete or inaccurate information is
Signature of Owner or Corporate Officer
grounds for denying this application and
can
give
cause
to
investigate
the
Printed name of signatory
legitimacy of all licenses the applicant
holds.
Title
Date Signed
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Parent category: Financial