Form Mf 100a - Fuel Tax License Application Page 2
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4Ownership Information
All applicants must complete this section. Failure to provide information below is grounds for denial of licensing. List names of all
owners, partners, or principal officers. Home addresses and phone numbers must be supplied along with each individual’s Social Security
Number. Attach an additional sheet if necessary.
Name
Title
Personal address
City
State
Zip
Social Security Number
Phone Number
Name
Title
Personal address
City
State
Zip
Social Security Number
Phone Number
Name
Title
Personal address
City
State
Zip
Social Security Number
Phone Number
Name
Title
Personal address
City
State
Zip
Social Security Number
Phone Number
South Dakota Tax License History
Do you have any current or canceled tax licenses issued by the South Dakota Department of Revenue?
Yes
No
If yes, please list below. (“Type” includes sales, use, contractors’ excise, motor fuel, liquor, cigarette, IFTA, IRP, etc.). Attach addi-
tional sheets if needed.
Type
License Number
Date of Operation
Type
License Number
Date of Operation
Type
License Number
Date of Operation
Fuel Types
Indicate the fuel product that you currently handle or plan on handling:
100% Ethyl Alcohol
100% Methyl Alcohol
Avgas
Compressed Natural Gas (CNG)
Dyed Biodiesel
Dyed Diesel
Ethanol Blend
Gasoline
Jet Fuel
Liquid Petroleum Gas (LPG)
Methanol Blend
Undyed Biodiesel
Undyed Diesel
Other - Please List:
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Parent category: Financial