Wyoming Department of Transportation                                                                         DO NOT WRITE IN THIS SPACE 
Fuel Tax Administration                                                                                 
Licensing Section                                                                                       
5300 Bishop Blvd.                                                                                      Date Issued:_______________________________ 
Cheyenne, Wyoming 82009-3340                                                                            
Phone (307) 777-4826                                                                                   Person Who Issued License:__________________ 
Fax (307) 777-4769                                                                                      
                                                                                                       License Number:___________________________ 
$25.00 fee per fuel type.  Each dealer location                                                         
requires a separate license.  Make checks payable to                                                   Check No:________________ Amount:_________ 
Wyoming Department of Transportation.                                                                   
                                                                                                       Expiration Date:____________________________ 
                                                                                                        
                     WYOMING MOTOR FUEL LICENSE APPLICATION 
                                                        NEW APPLICANT 
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                                      *** SECTION (A) LICENSE & FUEL TYPE *** 
                                                                            
                ¾  Please check the license and fuel type(s) that accurately apply to your business operation(s)      Example:  IF YOU ARE A 
                   DISTRIBUTOR IN WYOMING AND IMPORT AND EXPORT GAS AND DIESEL FUEL, MARK THOSE FIVE SPACES BELOW. 
 
                ¾  Please type or print legibly.  If any portion of the application is not complete or if the improper fee is sent, the application may be 
                   returned to you for correction, delaying the issuance of your respective license. 
 
                ¾  The annual fee for the license(s) will be twenty-five dollars ($25.00) per fuel type.   
 
_____SUPPLIER:                        Means a person that is subject to fuel tax laws of this state, registered with the  Internal Revenue Service for 
                                      transactions of motor fuel in the bulk transfer/terminal distribution system, and the position holder in a terminal or 
                                      refinery in or outside Wyoming.  A Supplier is also a person who produces alcohol or alcohol derivative substances 
                                      for blending with gasoline. 
 
_____DISTRIBUTOR:                     Means any person who, other than a dealer, receives fuel or blends fuel for distribution or resale in this state. 
 
_____IMPORTER:                        Means any person, other than a Supplier, who purchases fuel outside Wyoming for the purpose of transporting or 
                                      delivering, other than in the supply tank of a motor vehicle, the fuel into Wyoming for sale, use or distribution within 
                                      Wyoming. 
 
_____EXPORTER:                        Means any person, other than a Supplier, who purchases fuel inside Wyoming for the purpose of transporting or 
                                      delivering, other than in the supply tank of a motor vehicle, the fuel to another state or jurisdiction. 
                
                ¾  The license fee for a dealer is in addition to, and not included in, any other license type listed above. 
                
                ¾  A separate license will be issued for EACH dealer location. 
                
                ¾  The annual fee for EACH dealer location is twenty-five dollars ($25.00), per fuel type, per location.  (Regular, Premium, and 
                   Gasohol are all considered gasoline, Aviation Gas is also considered gasoline).  (Jet Fuel is considered Diesel) 
                
_____DEALER:                          Means any person who sells or offers to sell gasoline or diesel fuel at a specific location in Wyoming, including any 
                                      person selling or offering to sell aviation fuel or aviation gas at a Wyoming airport. {Includes retail locations such as 
                                      gas stations, key locks, card locks, and Fixed Base Operators at airports} 
Fuel Type:   
 
                A.) Gasoline ______                           B.) Diesel ______                                   C.) Ethanol______ 
               (Includes Aviation Gas type fuel and Gasohol)                   (Includes Kerosene and Jet fuel) 
 
                        ¾      You must enclose color photos of your bulk storage plant(s) with this application. 
                                                                            
                             ¾ You must enclose a legal description of your bulk plant(s) with this application. 
 
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1) Give date business will begin OR has begun:_______________________________________ 
 
2) Indicate projected number of gallons to be sold on an average monthly basis: 
 
Gasoline__________gal.  Aviation Fuel__________gal.  Jet Fuel__________gal.  Undyed Diesel__________gal.  Dyed Diesel__________gal. 
 
3) List total capacity of storage for fuel type(s) in Wyoming for each type of fuel per location. 
 
Gasoline__________gal.  Aviation Fuel__________gal.  Jet Fuel__________gal.  Undyed Diesel__________gal.  Dyed Diesel__________gal. 
 
4) Physical address, location, and type of bulk storage:______________________________________________________________________________ 
 
5) List the registration number(s) issued by the Wyoming DEQ for the bulk storage tanks:________________________________________________ 
                                                                                       
                                    *** SECTION (B) GENERAL INFORMATION *** 
                                                                                       
            ¾        It may be necessary to attach additional pages to accurately complete application.  Please type or print answers. 
                                                                                       
1)________________________________________________________________________________________________________________________________________ 
      Legal Name of Applicant (Corporate, LLC, Partner, or Individual Name) 
 
2)________________________________________________________________________________________________________________________________________ 
      DBA / Trade Name (Name Under Which Business Will be Operated) 
 
3)_______________________________________________________________________________                  ________________________________________________ 
                       Mailing Address                                                                                               E-Mail Address 
 
3a)_______________________________________________________________________________________________________________________________________ 
 City      County    State  Zip Code 
 
4)_______________________________________________________________________________________________   Inside City Limits  ____Yes    ____ No 
      Physical Address of Place of Business (NO POST OFFICE BOXES; attach additional pages if necessary) 
 
4a)_______________________________________________________________________________________________________________________________________ 
 City       County    Zip Code 
 
5)________________________________________________________________________________________________________________________________________ 
      Telephone Number                                            Your Toll Free Number (If applicable)                                    Fax Number 
 
6)  Federal Employer Identification Number(FEIN) for the Person, Company, or Entity Applying for this License:_________________________________________ 
**(You must include documentation from the Internal Revenue Service of this number with your motor fuels application---MUST MATCH EXACTLY) 
 
7)________________________________________________________________________________________________________________________________________ 
      Contact Person For Business                        Phone Number                                    Title
 
8)________________________________________________________________________________________________________________________________________ 
      Name Of  Person To Contact If Primary Contact Not Available Phone Number                                                       Title 
 
9) Is the Place of Business or Property: ______Owned by Applicant ______Leased           ______Rented    ______Other (Explain)____________________ 
 
9a) If rented or leased, name of Landlord/Lessor’s name:_________________________________________________________________________________________ 
 
10) Did you purchase an existing business location?_________  If so, from whom?__________________________________  Is this new construction?____________ 
 
11) List all other states where you are licensed in the motor fuel business ____________________________________________________________________________ 
    (Include copies, with this application, of your fuel licenses from these states showing the license number and type of license.) 
 
12) Name of supplier who provides you with fuel:________________________________________________________________________________________________ 
 
13) Have you ever been denied, or have you ever had a fuel licensed canceled or revoked: ______Yes       ______No                          Where: ______________
                                               (If yes attach letter of explanation.) 
 
14) List all states you plan to export fuel to and the license number issued by that state to you:_______________________________________________________ 
 
15) Describe any blending of fuel that you plan to do:__________________________________________________________________________________________ 
 
                                         *** SECTION (C) TYPE OF OWNERSHIP *** 
                                                                                       
    ¾   If you are an OUT-OF-STATE Corporation, LLC, or Limited Partnership, you MUST register with the Wyoming Secretary of State’s 
      Office (307-777-7311) before commencing business in Wyoming.  It is also required you maintain an active status and good standing with 
      the Wyoming Secretary of State. 
 
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      ¾      You must include documentation that you have met this requirement with your motor fuels application.             
 
      ¾    You must provide a copy of your financial statement for the previous calendar year if you are an Importer or Supplier. 
 
  1)                   ______  Corporation   *      ______  Limited Liability Company  *    ______  Limited Partnership*  
 
  1a)                  ______  Sole Proprietor      ______  General Partnership             _____  Joint Venture 
 
*2)  Incorporated Under the Laws of the State of:_______________________________________            Date of Incorporation:_______________________________ 
 
  3)  Date you registered with Wyoming Secretary of State’s Office:___________________      Wyoming Corporate ID Number:_______________________________ 
 
  4)  List all Owners, Partners, Members, or Corporate Officers of the Company or Business; Include Name, Address and Title. 
 
___________________________________________________________________________________________________________________________________________ 
Name                                                       SSN                     Title                                           Home Address            (Not business address)  
 
___________________________________________________________________________________________________________________________________________ 
Name                                                       SSN                     Title                                          Home Address             (Not business address)  
 
___________________________________________________________________________________________________________________________________________ 
Name                                                       SSN                          Title                                                 Home Address (Not business address)  
 
___________________________________________________________________________________________________________________________________________ 
Name                                                        SSN                    Title                                           Home Address            (Not business address)  
 
 5)_________________________________________________________________________________________________________________________________________ 
           Name and address of Manager(s) of Your Wyoming Business (Attach additional pages if necessary)     Phone Number(s) 
  
 6)  State of Wyoming Sales/Use Tax Number for this business:____________________________________________________________________________________ 
                                                                                   
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 
I declare that everything contained on this application is a true and accurate statement.  I, as owner, co-partner, or officer of the 
corporation, have the authority to sign this application.  As a new applicant I understand a BOND may be required in order to obtain the 
license.  The bond MUST be on file with the Department before a fuel license will be issued. 
 
SIGNED:___________________________________________________________________TITLE:______________________________ 
 
PRINTED NAME:__________________________________________________________________________DATE:________________ 
 
FTA-APP- 3-3-08 

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