0504E (2013/07) © Queen's Printer for Ontario, 2013 Disponible en français Page 1 of 6
Ministry of Finance 33 King St W PO Box 620 Oshawa ON L1H 8E9
Application to Register for Manufacturer, Wholesaler, Dyer, Importer, Exporter and Interjurisdictional Transporter Gasoline Tax Act and/or Fuel Tax ActEnquiries: 1 866 ONT-TAXS (1 866 668-8297)
1 800 263-7776 Teletypewriter (TTY)1. ApplicantLegal Name
Business or Trade Name Same as Legal Name Business No.
Language of Choice
English
French
2. Business AddressUnit/Apt/Suite Street Number and Name Lot/Concession/RR No./Postal Stn
City/Town Province/State Country Postal/Zip Code
(Area Code) Business Telephone No. Fax No. Email Address
3. Mailing Address Same as Business AddressUnit/Apt/Suite Street Number and Name Lot/Concession/RR No./Postal Stn
City/Town Province/State Country Postal/Zip Code
4. Head Office Address Same as Business Address Same as Mailing AddressUnit/Apt/Suite Street Number and Name Lot/Concession/RR No./Postal Stn
City/Town Province/State Country Postal/Zip Code
5. Type of Legal Entity Check R applicable box (one only):IndividualCorporationGeneral Partnership
Limited PartnershipLimited Liability PartnershipLimited Liability Company
AssociationCo-operativeJoint Venture
Non-Share CorporationTrust
6. List all Owners, Partners, Officers and/or DirectorsName (First, Last Name) Title (Area Code) Telephone No.
If insufficient space, attach list7. Contact Person(s)Name (First, Last Name) Title
(Area Code) Business Telephone No. Fax No. Email Address
Unit/Apt/Suite Street Number and Name/PO Box/Postal Stn/Rural Route City/Town Province/State Postal/Zip Code
Document(s) this contact person should receive. (Check R applicable boxes.)All or specify: Application Assessment Renewals Returns
Name (First, Last Name) Title
(Area Code) Business Telephone No. Fax No. Email Address
Unit/Apt/Suite Street Number and Name/PO Box/Postal Stn/Rural Route City/Town Province/State Postal/Zip Code
Document(s) this contact person should receive. (Check R applicable boxes.)All or specify: Application Assessment Renewals Returns
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8. Designation as a Collector and Manufacturer Registration CertificateComplete if you propose to manufacture and are applying for a Designation as a Collector and a Manufacturer Registration Certificate under the Gasoline Tax Act and/or Fuel Tax Act.
Gasoline Product TypeLitres Manufactured in the last 12 months
Estimated Litres to be Manufactured in the next 12 months
Gasoline
Ethanol Blended Gasoline
Denatured Fuel Ethanol
Aviation Fuel
Propane
Fuel Product Type
Clear Fuel
Coloured Fuel
Kerosene
Bio-Diesel
Manufacturing Plant(s) - For each location in Ontario, list the manufacturing plant details:
Name of Manufacturing Plant Address of Manufacturing Plant Type of Product Manufactured
Street No. and Name
City/Town Province Postal Code
Street No. and Name
City/Town Province Postal Code
Street No. and Name
City/Town Province Postal Code
If insufficient space, attach list
9. Designation as a CollectorComplete if you are a wholesaler or propose to wholesale and are applying for a Designation as a Collector under the Gasoline Tax Act and/or Fuel Tax Act.
Gasoline Product TypeLitres Manufactured in the last 12 months
Estimated Litres to be Manufactured in the next 12 months
Gasoline
Ethanol Blended Gasoline
Denatured Fuel Ethanol
Aviation Fuel
Propane
Fuel Product Type
Clear Fuel
Coloured Fuel
Kerosene
Bio-Diesel
Note: Sales at Wholesale = Sales to other wholesalers and/or retailers (not including your own service stations).
Is or will at least 51 per cent of your sales be at wholesale? . . . . . . Yes No
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10. Dyer Registration CertificateComplete if you propose to colour fuel and are applying for a Dyer Registration Certificate under the Fuel Tax Act. To qualify you must have:
i) terminal or northern terminal facilities, andii) total sales of coloured fuel from all proposed dye points owned or operated must be equal to or in excess of 51 per cent
of the collector’s total sales of coloured fuel during the 12 month period prior to application for a Dyer Registration Permit.“Terminal” qualifications: “A storage facility owned or operated by a collector that is capable of holding in storage fuel in bulk for subsequent sale by the collector to which not less than 70 per cent by volume of its receipts of fuel in each calendar year are transported or transferred by vessel or pipeline.”Terminals - Please list the location of each terminal:
Street No. and Name City/Town Province/State Postal/Zip Code
If insufficient space, attach list
“Northern Terminal” qualifications: “A storage facility situated in Ontario north of 46 degrees north latitude, owned or operated by a collector, that is capable of holding middle distillate fuels in storage for subsequent sale by the collector, to which not less that 90 per cent by volume of its receipts of middle distillate fuels in any year are transported by rail tank car, each such tank car transporting not less than 70,000 litres of middle distillate fuels to the storage facility.”Northern Terminals - Please list the location of each northern terminal:
Street No. and Name City/Town Province/State Postal/Zip Code
If insufficient space, attach list
Does at least one of your Terminals listed above qualify as a proposed Dye Point? . . . . . Yes No
Dye Point Terminals - Please list the location of each terminal you propose to colour fuel as a Registered Dyer at:
Street No. and Name City/Town Province/State Postal/Zip Code
If insufficient space, attach list
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11. Bulk Storage Location - For each location in Ontario, list the bulk storage facility details:
Address of Storage Facility Product Type Stored
Storage Tank Capacity
Owned or Leased
Street No. and Name
City/Town Province Postal Code
Owned
Leased to Others
Leased from Others
Street No. and Name
City/Town Province Postal Code
Owned
Leased to Others
Leased from Others
Street No. and Name
City/Town Province Postal Code
Owned
Leased to Others
Leased from Others
Street No. and Name
City/Town Province Postal Code
Owned
Leased to Others
Leased from Others
If insufficient space, attach list
12. Supplier Information - List supplier(s) that you will purchase or obtain gasoline and/or fuel from:Supplier Name Street No. and Name City/Town Province/State Postal/Zip Code
If insufficient space, attach list
13. Importer Registration CertificateComplete if you import or propose to import gasoline and/or fuel products in bulk into Ontario and are applying for an Importer Registration Certificate under the Gasoline Tax Act and/or Fuel Tax Act.List the details for each Gasoline and/or Fuel Type purchased below:
Gasoline Product TypeLitres Imported
in the last 12 monthsEstimated Litres to be imported
in the next 12 months Jurisdiction Product Imported from (Province/State/Country)
Gasoline
Ethanol Blended Gasoline
Denatured Fuel Ethanol
Aviation Fuel
Propane
Fuel Product Type
Clear Fuel
Coloured Fuel
Kerosene
Bio-Diesel
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14. Exporter Registration Certificate
Complete if you propose to export gasoline and/or fuel products in bulk out of Ontario and are applying for an Exporter Registration Certificate under the Gasoline Tax Act and/or Fuel Tax Act.
List the details for each Gasoline and/or Fuel Type purchased below:
Gasoline Product TypeLitres Exported
in the last 12 monthsEstimated Litres to be Exported
in the next 12 months Jurisdiction Product Exported
to (Province/State/Country)
Gasoline
Ethanol Blended Gasoline
Denatured Fuel Ethanol
Aviation Fuel
Propane
Fuel Product Type
Clear Fuel
Coloured Fuel
Kerosene
Bio-Diesel
15. Common Carrier Information - List transporter(s) who will transport your product(s) into and/or out of Ontario below:
Name of Transporter Street No. and Name City/Town Province/State Postal/Zip Code
If insufficient space, attach list
16. Interjurisdictional Transporter Registration CertificateComplete if you propose to transport gasoline and/or fuel products in bulk into and/or out of Ontario and are applying for an Interjurisdictional Transporter Registration Certificate under the Gasoline Tax Act and/or the Fuel Tax Acts.Product to be Transported: (Check R applicable boxes.)
Gasoline ProductGasolineEthanol Blended GasolineDenatured Fuel EthanolAviation FuelPropane
Fuel ProductClear FuelColoured FuelKerosene
Mode of Product Transportation: Motor Vehicle
Marine Vessel
Railway Pipeline Otherplease specify
Are you registered as an Interjurisdictional Carrier (IJC)? Yes No
If Yes, enter your International Fuel Tax Agreement (IFTA) Registration No.
If No, to obtain an Application for International Fuel Tax Agreement (IFTA) Registration visit our website at ontario.ca/ifta or contact the ministry at 1 866 ONT-TAXS (1 866 668-8297) or 1 800 263-7776 Teletypewriter (TTY).
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17. Owner of Product Information - List importer(s) and/or exporter(s) that you will transport your product(s) for below:
Owner Name (Importer/Exporter) Street No. and Name City/Town Province/State Postal/Zip Code
If insufficient space, attach list
18. Are you dealing in Bio-Diesel?If Yes, please state Bio-Diesel Blend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
DayMonthYear19. Date business commenced under your ownership . . . . . . . . . . . . . . . . . . . . . .
20. Certification
I certify that I am an authorized signing officer and all information given in this application is true, correct and complete.
Note: The first application for registration must be signed by the owner, director or officer of the company.First and Last Name (please print) Title
Signature Year DayMonth
It is an offence to make, participate in, assent to or acquiesce in the making of a false or deceptive statement in an application, as required under the Fuel Tax Act or Regulations and the Gasoline Tax Act or Regulations.
The personal information provided by you on this form is collected under the authority of the Gasoline Tax Act R.S.O. 1990, c. G.5 as amended and the Fuel Tax Act R.S.O. 1990 c.F.35 as amended, and will be used in the administration of the Act. Questions about this collection may be directed to a Program Information Officer with the ministry at 1 866 ONT-TAXS (1 866 668-8297) or 1 800 263-7776 Teletypewriter (TTY).