Form Dr 7064 - Fuel Distributors License Application Page 4
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7III. Ownership/Partnership Information
No If yes, on which Stock Exchange __________________
Yes
If your ownership is a corporation, is it publicly traded?
If publicly traded, what is your stock symbol? ______________ . Have you registered with the Colorado Secretary of State?
Yes
No
If your Corporation is publicly traded, list all equity share holders with an equity interest holding of 10% or more. All other types of ownership must
list all owners. A copy of page 2, can be made if additional space is needed. Pre-printed lists are allowed if all the requested information is provided.
(Name, Address, FEIN/SSN, Telephone, and Interest Owned)
Ownership Equity Interest % Telephone
(1) Owner or Partner Name (last, first, middle initial) (if corporation, state corporate name)
(
)
Address (residence or P.O. Box, street, city, state, ZIP)
SSN (FEIN if applicable)
Ownership Equity Interest % Telephone
(2) Owner or Partner Name (last, first, middle initial) (if corporation, state corporate name)
(
)
Address (residence or P.O. Box, street, city, state, ZIP)
SSN (FEIN if applicable)
Ownership Equity Interest % Telephone
(3) Owner or Partner Name (last, first, middle initial) (if corporation, state corporate name)
(
)
Address (residence or P.O. Box, street, city, state, ZIP)
SSN (FEIN if applicable)
Ownership Equity Interest % Telephone
(4) Owner or Partner Name (last, first, middle initial) (if corporation, state corporate name)
(
)
Address (residence or P.O. Box, street, city, state, ZIP)
SSN (FEIN if applicable)
Ownership Equity Interest % Telephone
(5) Owner or Partner Name (last, first, middle initial) (if corporation, state corporate name)
(
)
Address (residence or P.O. Box, street, city, state, ZIP)
SSN (FEIN if applicable)
Ownership Equity Interest % Telephone
(6) Owner or Partner Name (last, first, middle initial) (if corporation, state corporate name)
(
)
Address (residence or P.O. Box, street, city, state, ZIP)
SSN (FEIN if applicable)
IV. Corporation - Corporate Officers
Name
Title
Telephone
(
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Name
Title
Telephone
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)
Name
Title
Telephone
(
)
Name
Title
Telephone
(
)
Name
Title
Telephone
(
)
*
Any change of ownership or equity interest amounting to 10% or greater within a twelve month period requires
mandatory notification to the Colorado Department of Revenue within 30 days.
(Page 2)
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Parent category: Financial