Purchaser's Permit Application

The personal information on this form is being collected under the authority of the Gasoline & Motive Fuel Tax Act. The information will be used for licensing purposes and for necessary administration of the licence. If you have any questions regarding the collection and use of this information, please contact the Manager Program Services, Department of Finance, P.O. Box 3000, Fredericton, NB E3B 5G5. Telephone: 1-800-669-7070 or e-mail wwwfin@gnb.ca.

* Required fields

Part 1 - Applicant Information

Legal Name:

Business or Trade Name:

Business Number:

Preferred Language?

English French

Purchaser's Permit Type:

* Application Type

New Application

Renewal

Individual

Sole Proprietorship (one owner)

Partnership

Two or more persons - PARTNERSHIP NAME must be registered with the Corporate Affairs Branch of Service New Brunswick (506) 453-2703. List name and address of partners.

Corporation

Limited or incorporated company with directors and officers and must be registered with Corporate Affairs Branch of Service New Brunswick (506) 453-2703. List name and address of directors and officers.

Notes

Mailing Address:

Postal Code:

Civic Number:

Civic No. / P.O. Box:

Street Name:

Street Type:

Community:

Province:

Country:

Daytime Telephone:

Example: (506)555-1234

Fax:

Example: (506)555-1234

Email Address:

Physical Location of Business:

Same as above

Postal Code:

Civic Number:

Civic No. / P.O. Box:

Street Name:

Street Type:

Community:

Province:

Country:

Daytime Telephone:

Example: (506)555-1234

Fax:

Example: (506)555-1234

Contact Person:

(You or your representative if you are not available during the day)

Contact Name:

Daytime Telephone:

Example: (506)555-1234

Fax:

Example: (506)555-1234

Email Address: