Form Mft-5a - Application For Gasoline Jobber License Page 2
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214. State kind of products handled: ________________________________________________________________________________________________
________________________________________________________________________________________________________________________
15. If applicant operates retail dealer service stations in applicant’s name in New Jersey or sell on consignment or commission sales basis to any person,
complete the following:
(a) List location and storage capacity of each company-owned service station. (attach separate rider)
(b) List names and locations of the dealers to whom applicant delivers on consignment or commission basis. (attach separate rider)
16. Operation in New Jersey (gallons):
(a) Total estimated monthly sales ___________________________________ uses_____________________________________________________
(b) Number of gallons of gasoline sold by month in New Jersey to different types of customers.
Number of Different
Monthly Gallons
Customers
(Sales and Uses)
1. NJ Retail Dealers (not including company-operated)
_________________________
___________________________
2. Fleet Operators (at least five vehicles used in business)
_________________________
___________________________
3. Large customers (must purchase 2,000 gallons or more
annually and who have at least 300 gallon storage capacity)
__________________________
__________________________
4. Farmers
__________________________
__________________________
5. Others
__________________________
__________________________
6. Total Disposals
__________________________
__________________________
17. Source of Gasoline
Name of Supplier
Location
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
18. Does applicant hold a Federal Form 637? If so, identify the issuing IRS District Office, provide copy of 637 certificate and also copies of applicant’s last
two quarterly Form 720 reports filed with the IRS. ________________________________________________________________________________
19. Does applicant hold any other New Jersey Motor Fuels License? If yes, explain________________________________________________________
________________________________________________________________________________________________________________________
20. Has applicant or any related party ever had a New Jersey Motor Fuel License denied, suspended, canceled or revoked in New Jersey or any other
jurisdiction? If yes, explain:__________________________________________________________________________________________________
21. Does applicant have any outstanding liability or litigation? If yes, explain______________________________________________________________
________________________________________________________________________________________________________________________
22. Describe in detail applicant’s planned activity and need for this license________________________________________________________________
________________________________________________________________________________________________________________________
23. Is applicant registered for Petroleum Products Gross Receipts Tax as required by the Act? . . . . . . . . . . . . . . . . . . ¨ YES
¨ NO
24. Is applicant registered with the Division of Taxation for any other New Jersey State taxes? . . . . . . . . . . . . . . . . . . ¨ YES
¨ NO
25. The undersigned applicant states, (under penalty of perjury), that all the information contained in this application is true and accurate in every particular.
_________________________________________________________
___________________________________________________
Name of Applicant
Signature of Owner, Partner or Officer
___________________________________________________
Title
Date
The information submitted will assist this office in the processing of your license request.
The Division of Taxation reserves the right to conduct a thorough investigation prior to issuing this license.
N.J.S.A 54:39-31.1 Provides in part as follows:
A Gasoline Jobber License is subject to “payment of a license fee of $450.00 for a three year period and the filing of a bond in such form and amount as
provided by law. A Gasoline Jobber’s License shall not be assignable and shall be valid only for the gasoline jobber in whose name issued.”
MFT-5A
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