Form MC071 "Special Fuel Dealer's Application" - Nevada

What Is Form MC071?

This is a legal form that was released by the Nevada Department of Motor Vehicles - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2004;
  • The latest edition provided by the Nevada Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MC071 by clicking the link below or browse more documents and templates provided by the Nevada Department of Motor Vehicles.

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Download Form MC071 "Special Fuel Dealer's Application" - Nevada

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MOTOR CARRIER DIVISION
555 WRIGHT WAY
CARSON CITY, NV 89711-0600
(775) 684-4711
fax (775) 684-4619
www.dmvnv.com
For Office Use Only
Date Received
Date Approved
Date Issued
Initials
Account Number
SPECIAL FUEL DEALER'S APPLICATION
This Application must be typewritten or printed in ink, in its entirety, and be accepted and approved by the Nevada
Department of Motor Vehicles. A Special Fuel Dealer's License must be received prior to engaging in business in the State of
Nevada. Please mail this original application, with the appropriate attachments to the address shown above.
Indicate fuel types being sold
{ } CNG
{ } LPG
1.
Applicant's name, if a corporation or partnership must match the name as shown on your Corporate Documents or
Partnership Agreement:________________________________________________________________________
2.
DBA or Trade Name, if different:_________________________________________________________________
3.
Location of Business Office_____________________________________________________________________
(Street Address)
__________________________________________________________________________________________________
(City, State, Zip)
__________________________________________________________________________________________________
(Area Code, Telephone Number, Fax Number)
4.
Federal Employer Identification Number or Social Security Number: _____________________________________
5.
All correspondence regarding this account is to be mailed to (if different from #3 above)
__________________________________________________________________________________________________
(Street Address)
__________________________________________________________________________________________________
(City, State, Zip)
6a.
Address where books and records are maintained (if different from #3 above)
__________________________________________________________________________________________________
(Street Address)
__________________________________________________________________________________________________
(City, State, Zip)
b.
Person to contact regarding all licensing activities:
__________________________________________________________________________________________________
(Name, Telephone Number, Fax Number)
c.
Person to contact regarding all tax reporting activities:
__________________________________________________________________________________________________
Mc071 (12/2004)
MOTOR CARRIER DIVISION
555 WRIGHT WAY
CARSON CITY, NV 89711-0600
(775) 684-4711
fax (775) 684-4619
www.dmvnv.com
For Office Use Only
Date Received
Date Approved
Date Issued
Initials
Account Number
SPECIAL FUEL DEALER'S APPLICATION
This Application must be typewritten or printed in ink, in its entirety, and be accepted and approved by the Nevada
Department of Motor Vehicles. A Special Fuel Dealer's License must be received prior to engaging in business in the State of
Nevada. Please mail this original application, with the appropriate attachments to the address shown above.
Indicate fuel types being sold
{ } CNG
{ } LPG
1.
Applicant's name, if a corporation or partnership must match the name as shown on your Corporate Documents or
Partnership Agreement:________________________________________________________________________
2.
DBA or Trade Name, if different:_________________________________________________________________
3.
Location of Business Office_____________________________________________________________________
(Street Address)
__________________________________________________________________________________________________
(City, State, Zip)
__________________________________________________________________________________________________
(Area Code, Telephone Number, Fax Number)
4.
Federal Employer Identification Number or Social Security Number: _____________________________________
5.
All correspondence regarding this account is to be mailed to (if different from #3 above)
__________________________________________________________________________________________________
(Street Address)
__________________________________________________________________________________________________
(City, State, Zip)
6a.
Address where books and records are maintained (if different from #3 above)
__________________________________________________________________________________________________
(Street Address)
__________________________________________________________________________________________________
(City, State, Zip)
b.
Person to contact regarding all licensing activities:
__________________________________________________________________________________________________
(Name, Telephone Number, Fax Number)
c.
Person to contact regarding all tax reporting activities:
__________________________________________________________________________________________________
Mc071 (12/2004)
(Name, Telephone Number, Fax Number)
7a.
Corporations: List full name, title, mailing address and phone number of corporate officers, directors and shareholders
with a controlling interest in the corporation. (Controlling shareholder means all shareholders if there are 15 or less, if
more than 15 shareholders, shareholders with five percent or more ownership interest.)
Partnerships: List full name, mailing address, phone numbers and social security numbers of general or limited
partners.
Individual/Sole Proprietorship: List spouses name and social security number.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Attach additional list if necessary.
d.
Has any of the persons listed in question 1 through 7a been convicted of any felony or misdemeanor involving motor
vehicle fuel or diesel taxes? Yes ____ No ____
If yes, explain : _________________________________________________________________________________
______________________________________________________________________________________________
8.
Has the corporation, partnership or person had any type of license involving motor vehicle fuel or special fuels
suspended, revoked or canceled for cause within the last ten years?
Yes ____ No ____
If yes, explain: __________________________________________________________________________________
_______________________________________________________________________________________________
Mc071 (12/2004)
9.
Federal (637) Tax-Free Number ____________________________________________________________________
10.
Does any of the persons listed in 1 through 7a hold an IFTA, Special Fuel Users, Motor Carrier or IRP license issued
by the Nevada Department of Motor Vehicles?
Yes ____ No ____
If yes, please list the account name(s) and license number(s):
______________________________________________________________________________________________
______________________________________________________________________________________________
11a.
Date of Incorporation, Partnership or business began: ________________________________________________
State of Incorporation, Partnership or business located:_______________________________________________
Nevada Resident Agent, if applicable:
____________________________________________________________________________________________
(Name, Address, City State Zip, Telephone Number, Fax Number)
b.
Is the corporation in good standing in the state of incorporation? Yes ____ No ____
12a.
How many years has your corporation, partnership or company been in business? __________________________
b.
How many years in the State of Nevada?__________________________________________________________
13a.
If your business currently uses a dba or tradename, please list: ________________________________________
___________________________________________________________________________________________
b.
If your business used a dba or tradename in the past, please list _______________________________________
___________________________________________________________________________________________
Yes
NO
14.
Do you plan to take physical possession of fuel in Nevada?
15.
Do you plan to take title to the special fuels?
16.
Do you expect to maintain bulk storage facilities in Nevada? If yes list all physical
locations.________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
17.
Do you plan to sell LPG or CNG on consignment?
18.
Do you own or control other businesses in the petroleum industry? If yes, explain:
Attach additional list if necessary._____________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
19.
Do you or any officer, director or controlling shareholder own or control any petroleum
transport equipment for use in Nevada? If yes, explain:___________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
20.
List any person listed in question 1 through 7a that is or has been an officer, director, controlling shareholder, partner
or sole proprietor of any entity which currently has or has had, within the last seven years, a Nevada Special Fuel
Dealer's License:______________________________________________________________________________
Mc071 (12/2004)
___________________________________________________________________________________________
___________________________________________________________________________________________
21.
Is this company licensed as an importer, exporter, wholesaler, distributor, or supplier in any other state or jurisdiction?
Yes
No
If yes, list license name, number and state:___________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
22.
In the last ten years has this company been involved in any petroleum products business that has filed for bankruptcy.
If so, explain:______________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
23.
Does this company currently owe any delinquent amounts to any Federal, State or Local Government? If yes, explain:
______________________________________________________________________________________________
____________________________________________________________________________________________
BOND CALCULATION
24.
What is the expected number of gallons of special fuel products that will be sold in NV during a one year period?
CNG ______________
LPG_______________
Total:_____________________
You will be notified by the Department of the amount of bond necessary to receive your license.
25.
List the company names and addresses you anticipate purchasing CNG or LPG from: ________________________
______________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
26.
If this is a newly acquired business, from whom did you acquire the business? _______________________________
If known, what was the account number? ____________________________________________________________
How many gallons of fuel were in storage tanks at the time of purchase? CNG ___________ LPG _____________
27.
Attach a copy of your Articles of Incorporation and a copy of the Current List of Officers and Directors filed with the
Nevada Secretary of State's Office, if applicable.
Mc071 (12/2004)
AFFIDAVIT OF APPLICANT(S)
The undersigned hereby swears or affirms under penalty of perjury that I am duly authorized to make the foregoing Application,
and hereby swear or affirm that the Application and all attachments are true and correct representations of the premises to be
licensed and agree that the place of business, if licensed, may be inspected during business hours, or at any time business is
being conducted on the premises, by officials and agents of the Nevada Department of Motor Vehicles, for purposes of
determining compliance with the NRS 366.
___________________________________________
____________________________________________________
Authorized Signature
Spouse’s Signature, if applicable
___________________________________________
____________________________________________________
Print or Type Applicant Name
Print or Type Spouse’s Name
(Corporate Officer, Partner, Individual)
___________________________________________
Title
STATE OF __________________________________
County of ___________________________________________
Signed and sworn to before me this ________ day of _______________, 20__. My Commission Expires ____________
____________________________________
Notary Public
******************************************************************************************************************************************
FOR OFFICE USE ONLY
Bond Amount Required: _____________________________
Date Notified: ________________________________
Bond Amount Received: ____________________________
Date Bond Received: __________________________
Initials: ___________
Mc071 (12/2004)
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