Form Mf-26 - Application For Liquid Fuels Carrier'S License And Certificates
ADVERTISEMENT
1
2Fee Enclosed
KANSAS DEPARTMENT OF REVENUE
FOR OFFICE USE—LEAVE BLANK
CUSTOMER RELATIONS
Fee is $10.00 per vehicle
License No.
TOPEKA, KANSAS 66625-8000
MAKE REMITTANCE PAYABLE TO
"Kansas Department of Revenue "
Phone Number : (785) 368-8222
Date Mailed
Fax (785) 296-2703
APPLICATION FOR LIQUID FUELS CARRIER'S LICENSE AND CERTIFICATES
1.
Legal name
2.
DBA name
3.
Business mailing address
Street Address or Post Office Box
City
State
Zip Code
4.
Business location address
Street Address
City
County
State
Zip Code
5.
Federal Employers Identification Number
6.
Business Phone Number (
)
FAX Number (
)
7.
Check type of ownership:
Individual
Partnership
Corporation
Other
8.
List owner, partners, corporate officers and all stockholders who own 5% or more of company stock.
Social Security
Telephone
Name
Address
Title
Number
Number
9.
The correct description of each vehicle which applicant will use in Kansas in such business, and for which the applicant desires a liquid fuels
carrier's license certificate, is: (List here separately each vehicle that transports liquid fuels or motor-vehicle fuels from any refinery, place of
production or manufacture, or pipe-line terminal, or across the state line, in quantities of 120 gallons or more over any of the public highways of
this state; and also each vehicle that transports such fuels in quantities of 3,500 gallons or more over any of the public highways of this state from
any point of origin other than a refinery, place of production or manufacture, or pipe-line terminal.) Attach list of additional vehicles if
necessary.
Kind of Vehicle
Gallons
Leave Blank
Make and Year
Truck/Truck-Tractor
VIN No.
Carrying Capacity
Certificate No.
10. What type or types of fuel or fuel additive are you hauling in the State of Kansas?
Diesel,
Gasoline,
Ethanol,
Methanol,
Kerosene,
Alcohol,
Propane,
Compressed Natural Gas,
E-85,
Jet Fuel,
Other, Please describe
11. Are you a licensed Distributor in the State of Kansas?
Yes
No, Distributor License # __________ If yes, do you only haul fuel for own
retail locations located in the State of Kansas?
Yes
No
12.
Are the above described vehicles properly painted in compliance with the law and the rules and regulations and will be painted before operating
in Kansas.
Yes
No (See back K.A.R. 92-3-6)
13.
Are the applicant(s) at least 18 years of age?
Yes
No
14.
Are you or any partner, corporate officer or stockholder owning more than 5% of company stock delinquent in payment of any motor fuel taxes,
interest or penalty to a taxing agency in any state or to the federal government?
Yes
No
15.
Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of a felony involving theft
within 5 years immediately preceding the date of making application in this or any other jurisdiction?
Yes
No
16.
Have you or any partner, corporate officer or stockholder owning more than 5% of company stock been convicted of a felony involving fraud or
tax evasion in this or any other jurisdiction?
Yes
No
OVER
MF-26 (Rev. 06/09)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial