Form Mf-26 - Application For Liquid Fuels Carrier'S License And Certificates Page 2
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1
217.
Have you or any partner, corporate officer or stockholder owning more than 5% of company stock had a motor fuel license revoked for cause in
another state?
Yes
No
18.
Do you or any partner, corporate officer or stockholder owning more than 5% of company stock intend to carry on the business authorized by the
license as agent of another?
Yes
No
19.
If you answered yes to any question 14-19, please explain on a separate sheet of paper.
State of
,
County of
, ss:
I,
, first being fully sworn, state that the above application, and all statements contained
(Print Name)
therein, are true and correct under the penalty of perjury.
(Signature of Owner, Partner, Corporate Officer, or Person Authorized by Attached Power of Attorney)
(Title)
Subscribed and sworn to before me, this
day of
20
My commission expires
20
(Notary Public)
INSTRUCTIONS
Line 9 MAKE AND YEAR—This can be abbreviated, as an example, "IHC' 96" or "Chev' 99."
KIND OF VEHICLE—Show whether vehicle is a Truck or Truck-Tractor.
VEHICLE IDENTIFICATION NUMBER (VIN)—On a truck or truck-tractor, give the VIN only. It is not necessary to
describe the semi-trailer.
CARRYING CAPACITY—This figure (in gallons) is to be inserted if the cargo carrying capacity of the vehicle is 120 gallons
or more, up to and including 3,500 gallons. If vehicle is a truck-tractor, show cargo carrying capacity of towed unit.
•
ITEM (13)—KAR 92-3-6. States marking of vehicles transporting liquid fuels. Each vehicle used in transporting liquid fuel,
which is subject to the law pertaining to the transportation of liquid fuel, shall be marked or lettered as follows: (a) The liquid fuel
carrier's name and address shall appear in plain letters not less than two inches in height on a sharply contrasting background on
each side of the vehicle; (b) The liquid fuel carrier's license certificate number shall appear in plain letters not less than two inches
in height on a sharply contrasting background on each side of the vehicle.
•
WHO MAY SIGN APPLICATION—Only the Individual Owner; Partner; Corporate Officers; listed on the application or a person
who has been duly authorized as Attorney-in-fact by proper Power of Attorney which has been filed in this office; may sign the
application.
•
VEHICLES SOLD, LEASED, OUT OF SERVICE—When any vehicle which has been licensed is no longer used or has been sold
or leased, under a long term lease, to another carrier, the LFCL certificate should be sent in immediately with written instructions
for cancellation. If the certificate has been lost, send in letter with vehicle information to request the license be canceled.
•
You must report any change in ownership including a change in partners, corporate offices or stockholders owning 5% or more of
company stock within 30 days of the change.
•
ENCLOSE FEE OF $10.00 PER VEHICLE
This completed application or inquiries concerning this application should be directed to:
CUSTOMER RELATIONS
MOTOR FUEL TAX
KANSAS DEPARTMENT OF REVENUE
915 SW HARRISON ST
TOPEKA, KANSAS 66625-8000
OR
PHONE: (785) 368-8222
FAX: (785) 296-2703
MF-26 (Rev. 06/09)
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