Form 20mf - Nebraska Motor Fuels License Application Page 3
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315 Will you export fuel from Nebraska? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, list the state(s), license number(s), and type of fuel. Attach additional schedule, if necessary.
State
License Number
Type of Fuel
State
License Number
Type of Fuel
16 Have any licenses or permits issued to you under the motor fuel laws of another state been suspended, cancelled or revoked? . .
YES
NO
If Yes, list the state(s) and license number(s). Attach additional schedule, if necessary.
State
License Number
State
License Number
State
License Number
17 Has any owner, partner, or corporate officer of this business been convicted of a felony in the last ten years? . . . . . . . . . . . . . . . .
YES
NO
18 Do you have storage tanks that are required to be registered with the State Fire Marshal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, are all storage tanks registered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
19 Do you sell motor fuels or compressed fuel through metered dispensing devices (pumps)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If Yes, are the dispensing devices registered with the Nebraska Department of Agriculture Weights and Measures Division? . . . . .
YES
NO
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MULTIPLE RETAIL LOCATION INFORMATION
• Attach additional page if necessary. Include all fuel types.
What type of fuel is sold from this retail location? Check all that apply.
What type of fuel is sold from this retail location? Check all that apply.
Motor Vehicle Fuels
Aircraft Fuels
Diesel Fuel
Compressed Fuel
Motor Vehicle Fuels
Aircraft Fuels
Diesel Fuel
Compressed Fuel
Business Name
Business Name
Business Location Street Address
Business Location Street Address
City
State
Zip Code
City
State
Zip Code
What type of fuel is sold from this retail location? Check all that apply.
What type of fuel is sold from this retail location? Check all that apply.
Motor Vehicle Fuels
Aircraft Fuels
Diesel Fuel
Compressed Fuel
Motor Vehicle Fuels
Aircraft Fuels
Diesel Fuel
Compressed Fuel
Business Name
Business Name
Business Location Street Address
Business Location Street Address
City
State
Zip Code
City
State
Zip Code
ELECTRONIC DATA INTERCHANGE (EDI)
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• Before a license can be issued, you must state your ability to file electronically (EDI).
Translation by (Check one):
EDI E-Mail Address (if different from #9)
Commercial EDI Software
Internally Created From NDR Software Development Guide
Online Filing (Forms 74, 80, and 86 only)
Pursuant to the provisions of Section 66-718 of the Nebraska Revised Statutes, applicant agrees as follows:
The signature of taxpayer or its authorized agent shall be deemed to appear on such electronically filed reports
or returns, as if actually appearing. All reports and returns filed electronically are deemed by taxpayer to be truthful,
accurate, and complete statements made under penalty of perjury. Taxpayer’s electronically filed reports and returns
are in a form and manner compatible with the State of Nebraska, Department of Revenue’s equipment, software,
facilities, and electronic filing standards. Any electronic filing not in conformity shall be deemed a failure to file such
report or return and taxpayer shall be subject to all applicable penalties prescribed by law. Taxpayer is responsible
for all costs associated with the transmission of such electronically filed reports and returns. The place of performance
pursuant to this application shall be Lincoln, Nebraska.
sign
here
Signature of Owner, Partner, Member, Corporate Officer, or Person Authorized by Attached Power of Attorney
Date
(
)
Title
Telephone Number
Mail this application and any fees and bonds to:
MOTOR FUELS DIVISION, P.O. BOX 98904, LINCOLN, NEBRASKA 68509-8904
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