Form Dmf-2 - Application For Recognition As A Qualified Distributor
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1
2Division Use Only — DLN Stamp
Division Use Only — Date Stamp
Date Completed
Return to:
Division of Taxation
PO Box 189
Pursuant to NJSA 54:39-101 et seq
Trenton, NJ 08695-0189
10-2010
Application for Recognition as a
Form DMF-2
Qualified Distributor
Section 1 – Business Information
Federal ID #
IRS 637 #
New Jersey Tax ID#
Does
your
company
Yes
have internet access?
No
Business Name
Webpage Address
Trade Name
Phone Number
Fax Number
Physical Address
Mailing Address
Books and Records Address
Section 2 – Contact Information
If you wish to give an attorney or accountant access to your tax information, you must supply us with an Appointment of Taxpayer
Representative form (Form M-5008-R) giving us the authority to release confidential information to them.
Contact for Registration
Title
Telephone Number
Email Address
Contact for Reporting
Title
Telephone Number
Email Address
Individual Completing this form
Title
Telephone Number
Email Address
Section 3 – Types of Products Handled
Check each type of product with which you will be dealing in New Jersey
Gasoline
LPG
Dyed Kerosene
Undyed Kerosene
Gasohol
Undyed Diesel
Undyed Biodiesel
Aviation Fuel
Fuel Grade Alcohol
Dyed Diesel
Dyed Biodiesel
Other – List each other product
Section 4 – Fuel Suppliers
List Suppliers and provide requested information. Use a rider if necessary.
How product
Name
Phone #
Federal ID #
License #
Products
Terminal #
is received
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