PDO-100
License Application for Distributors and Special Fuel Dealers
New license application
Renewal of existing license
(include $25 license fee with application)
(electronically pay $25 renewal fee at )
Legal name
Daytime phone
Minnesota tax ID number
Doing business as
Federal ID number
Street
County
Email
City
State
Zip code
Fax
Mailing address (if different):
Street
City
State
Zip code
Type of business
Individual
Partnership
Corporation
Limited Liability Company (LLC)
Governmental agency
List corporate officers, partners or members of association (attach a list for additional officers):
Name
Title
Address
Phone
Accounting information:
Fuel tax preparer name
Phone
Fax
Address
Email
License applied for:
Distributor ($3,000 bond is required for all new applicants)
Qualifiers (check one):
Receive petroleum products in Minnesota that are consigned to me from a terminal or refinery for storage and subsequent distribution by tank car or
tank truck. Current petroex number and terminal:
Produce, manufacture or refine petroleum products in Minnesota.
Import petroleum products into Minnesota by boat, barge or pipeline for storage and subsequent delivery.
Hold a license and perform a function in an adjoining state equivalent to that of a distributor under Minnesota law.
Enter your license number for each state below
Iowa
North Dakota
South Dakota
Wisconsin
Special fuel dealer ($1,000 bond is required for all new applicants)
Bulk purchaser (no bond required). Individual users of tax-free special fuels.
Qualifiers (check one):
State or local government
LPG
CNG/LNG
Jet fuel
Filing method (check one):
Web (bulk purchasers and special fuel dealers only)
Web and text files
EDI files — software provider
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we must advise you of the following:
• This information may be used to deny the issuance or renewal of your license if you owe the Minnesota Department of Revenue delinquent tax, penalties or
interest.
• Under the Federal Exchange of Information Act, the Department of Revenue is allowed to supply this information to the Internal Revenue Service.
• Failing to supply this information may jeopardize or delay the issuance of your license or processing of your renewal application.
I acknowledge that by becoming licensed as a petroleum distributor/special fuel dealer, I will have record keeping/reporting requirements and responsibilities. I agree to comply with
the applicable tax statutes as a condition of my license, and declare that the information given in this application is true, correct and complete to the best of my knowledge and belief.
Authorized signature
Title
Date
Daytime phone
Mail this form and financial statements to: Minnesota Revenue, Mail Station 3333, St. Paul, MN 55146-3333. Phone: 651-296-0889. Minnesota Relay 711 (TTY).
(Rev. 4/13)