Form Mf-42 - Application For Motor Vehicle Fuel And Special Fuel Distributor'S License
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1
2FOR OFFICE USE—LEAVE BLANK
KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
License No.
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 DISTRIBUTOR'S 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.
List the exact locations in Kansas where applicant intends to operate a distributing business, including resale to other distributors
or dealers. Be sure to list location type: Retail: RL
Bulk Plant: BP
Refinery: RF
Office: OF Pipeline/Terminal: PT
Street Address
City
County
Location Type
Inception Date
For Office Use Only
Location No.
1.
(List exact location, use street numbers and legal description. If on railroad property, railroad lease numbers sufficient.)
2.
3.
4.
9.
Is a Distributor's License in effect for another distributor at the above location(s) at this time?
Yes
No
10
If a successor to a former distributor, give trade name of such distributor
11.
Indicate whether location is owned or leased by the applicant
12.
Amount of storage capacity, in gallons, and product type of each tank in place at each location is:
Location 1
Location 2
Location 3
(Insert the gallonage and product type in the above spaces for the number of tanks to be used)
13. Are you the first distributor selling or offering for sell motor fuels at the terminal rack or importing fuel to Kansas?
Yes
No
14. Estimated annual tax liability
15. Contact person for tax return inquiries:
Name:
Phone Number:
Fax Number :
E-mail address:
16. Do you transport your own product?
Yes
No
If yes, please show your Liquid Fuels Carriers Number
If no, who transports this product?
17. Are the applicant(s) at least 18 years of age?
Yes
No
18. Are you or any partner, corporate officer or stockholder owning more than 5% of company stock delinquent in payment of any
Yes
No
motor fuel taxes, interest or penalty, to a taxing agency in any state or to the federal government?
MF-42 (Rev. 08/11)
(CONTINUED ON REVERSE SIDE)
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