WYOMING DEPARTMENT OF TRANSPORTATION
FUEL TAX ADMINISTRATION
5300 Bishop Boulevard, Cheyenne, WY 82009 - 3340
Phone: 307-777-4828 Fax: 307-777-4769

MOTOR FUEL LICENSE APPLICATION - ADDITIONAL RETAIL LOCATION FORM
*Please include $25.00 Licensing Fee per Fuel Type per Location

FEIN/SSN: Store No. __________
Legal Name:
Mailing Address: Trade Name: ____________________

1. New Location: _________ Renewal Location: ___________ Start of Business Date: _______________
(a) If this is a New Location – Is this a new construction? Y / N Did you purchase an existing retail fuel location? Y / N
(b) If you purchased an existing retail fuel location, from whom? ______________________________________________________
2. Physical Address:____________________________________ City:_____________________ County: _____________________
State: _________ Zip Code: ______________ Is this location: In City Limits ________ Outside City Limits ________
3. Type of Fuel Sold: Gasoline ______ Diesel ______ Supplier: ________________________________________________
4. List Total Capacity of Storage for each fuel Type:
Gasoline __________ gal. Aviation Fuel __________ gal. Jet Fuel __________ gal. Undyed Diesel __________gal. Dyed Diesel __________ gal.
5. DEQ Facility ID # ______________________________ DOR Sales/Use Tax # ______________________________________
6. Contact Person for Location: ______________________ Telephone Number: _______________ Fax Number: ________________

FEIN/SSN: Store No. ___________
Legal Name:
Mailing Address: Trade Name: _____________________

1. New Location: _________ Renewal Location: ___________ Start of Business Date: _______________
(a) If this is a New Location – Is this a new construction? Y / N Did you purchase an existing retail fuel location? Y / N
(b) If you purchased an existing retail fuel location, from whom? ______________________________________________________
2. Physical Address:__________________________________ City: _____________________ County: ______________________
State: ________ Zip Code: _____________ Is this location: In City Limits ________ Outside City Limits ________
3. Type of Fuel Sold: Gasoline ______ Diesel ______ Supplier: ________________________________________________
4. List Total Capacity of Storage for each fuel Type:
Gasoline__________ gal. Aviation Fuel __________ gal. Jet Fuel __________ gal. Undyed Diesel __________gal. Dyed Diesel __________ gal.
5. DEQ Facility ID # ______________________________ DOR Sales/Use Tax # ______________________________________
6. Contact Person for Location: ______________________ Telephone Number: _______________ Fax Number: ________________

I declare that everything contained on this application is a current, true, and correct statement. I, as owner, co-partner, or officer of the corporation have the authority to sign this application. As an existing licensee, I understand that the Department may require a Surety Bond be filed as a condition of future licensing pursuant to W.S. 39-17-106 and W.S. 39-17-206

SIGNED: __________________________________________________________ TITLE: ______________________________

PRINTED NAME: __________________________________________________ DATE: ________________________________

20080303

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