Form Mf-44 - Application For Motor Vehicle Fuel And Special Fuel Importer/exporter License
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2FOR OFFICE USE—LEAVE BLANK
KANSAS DEPARTMENT OF REVENUE
License No.
CUSTOMER RELATIONS
915 SW HARRISON ST.
Date License Issued
TOPEKA, KANSAS 66625-8000
Date Mailed
Phone Number: (785) 368-8222
Fax: (785) 296-4993
APPLICATION FOR MOTOR VEHICLE FUEL AND SPECIAL FUEL
IMPORTER/EXPORTER LICENSE
1.
Business name
2.
Business mailing address
Street Address or Post Office Box
City
State
Zip Code
3.
Business location address
Street Address
City
County
State
Zip Code
4.
Federal Employers Identification Number
5.
Business Phone number
Fax Number
6.
Check type of ownership:
Individual
Partnership
Corporation
Other
7.
List owner, partners, corporate officers and all stockholders who own 5% or more of company stock.
Social Security
Telephone
Name
Address
Title
Number
Number
8.
Do you transport your own products?
Yes
No
If yes, please show your Liquid Fuel Carriers License #
If no, who transports this product?
I
9.
For what purpose will this license be used?
mporting
Exporting
Start Date
10. Estimated Annual tax liability?
11. Contact person for tax return inquiries:
Name:
Phone Number:
Fax Number:
E-mail address:
12. Are the applicant(s) at least 18 years of age?
Yes
No
13. Are you or any partner, corporate officer or stockholder owning more than 5% of company stock delinquent in payment of any
motor fuel taxes, interest or penalty, to a taxing agency in any state or to the federal government?
Yes
No
14. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of a felony
involving theft within 5 years immediately preceding the date of making application in this or any other jurisdiction?
Yes
No
15. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of a felony
involving fraud or tax evasion in this or any other jurisdiction?
No
Yes
16. Have you or any partner, corporate officer or stockholder owning more than 5% of company stock had a motor fuel license
revoked for cause in another state?
Yes
No
17. Do you or any partner, corporate officer or stockholder owning more than 5% of company stock intend to carry on the business
authorized by the license as agent of another?
Yes
No
18. If you answered yes to any question 13-16, please explain on a separate sheet of paper.
Applicant hereby gives its irrevocable consent that actions may be commenced against it in the proper court of any county in this state
in which a cause of action may arise or in which the plaintiff may reside, by service of process on the Secretary of State. Applicant
stipulates and agrees that such service shall be taken and held, in all courts, to be as valid and binding as if due service had been
made upon the applicant personally, or upon the president and secretary, if a corporation. (Secretary of State will notify a pplicant by
registered mail of any action started against him.)
State of
County of
, ss:
I,
, first being fully sworn, state that the above application, and all
statements contained therein, are true and correct under the penalty of perjury.
(Signature, of Owner, Partner, Corporate Officer, or Person Authorized by a Power of Attorney)
(Title)
Subscribed and sworn to before me, this
day of
20
My commission expires
20
(Notary Public)
MF-44
(Rev. 8/11)
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Parent category: Financial