Form Mft-5r - Application For Renewal Of A Gasoline Jobber License - 2000
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1
2STATE OF NEW JERSEY
USE FOR
MFT-5 R (2-00, R-3)
Division of Taxation
RENEWAL
MOTOR FUEL TAX
Application Required by
ONLY
PO Box 189
NJ Motor Fuel Tax Law
Trenton, NJ 08695-0189
APPLICATION FOR RENEWAL OF A GASOLINE JOBBER LICENSE
Application is hereby made by the undersigned for renewal of a Gasoline Jobber’s License to operate in the State of New Jersey in compliance with Chapter
39 of Title 54, Taxation, of the Revised Statutes and the Acts amendatory thereof and supplemental thereto. Every Jobber’s License is subject to the filing of
a bond in such form and amount as provided by law. This license is also subject to payment of a renewal fee of $450.00 for a three year period. Please
return this application and a check or money order made payable to: State of New Jersey-MFT, on or before April 1.
Make any necessary changes below for 1 - 5
-
-
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1. FID #
OR
Soc. Sec. # of owner
2. Name________________________________________________________________________________________________________________
(If INCORPORATED - give Corp. Name; IF NOT - give Last Name, First Name, MI of owner(s))
3. Trade Name__________________________________________________
5. Mailing Name and Address -
(if different from farm address)
4. Business Location:
Name________________________________________________
Street_______________________________________________________
Street________________________________________________
City__________________________________________ State
City____________________________________ State
-
Zip Code
Zip Code
-
(Give 9-digit Zip)
(Give 9-digit Zip)
Please fill in all information below:
6. Type of ownership (check one):
¨ NJ Corporation
¨ Sole Proprietor
¨ Partnership
¨ Out-of-State Corporation
¨ Limited Partnership
¨ Other - explain___________________________________________________________________________________________________
7. Telephone Numbers: Contact Person ___________________________________________
Title__________________________________
789
Daytime: (
) ________ - __________________Ext_________
Evening: (
) ________ - _________________Ext_________
8. Provide the following information for ALL owners, partners or responsible corporate officers. (If more space is needed, attach rider).
%
NAME
SOCIAL SECURITY NUMBER
HOME ADDRESS
(Last Name, First, M.I.)
OWNED
TITLE
(Street, City, Zip)
NOTE: On a separate sheet of paper provide the names of stockholders owning 10% or more of the outstanding shares of stock in the corporation.
9. List parent company, wholly owned subsidiaries, and/or affiliates ___________________________________________________________________
________________________________________________________________________________________________________________________
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