Form Ibr-3 - Idaho Fuel Distributor License Application - 2010
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4IBR-3
EFO00204
06-17-2010
IDAHO FUEL DISTRIBUTOR LICENSE APPLICATION
IDAHO STATE TAX COMMISSION
800 PARK BOULEVARD, PLAZA IV
P.O. BOX 36
BOISE, IDAHO 83722
1.
Federal employer identification number
2. Social security number
4. Doing business as (DBA) name
3.
Legal business name (See instructions.)
5.
Type of business
___Sole Proprietorship
___Partnership
___S Corporation
___Corporation
___Limited Liability Corporation
___Nonprofit
___Government
___Fiduciary
___Limited Liability Partnership
Date incorporated
7. State incorporated in
8. Tax year end
9. Date business began
6.
10.
Purpose of application
___New business
___Change in business name
___Change in partners ___%
___Reregistration
___Change in business type
Mailing address
Street or PO Box
City
State
Zip Code
11.
Location of business
Street address
City
State
Zip Code
12.
13.
Mailing address
Street or PO Box
City
State
Zip Code
for report forms
15. Telephone number
14.
Contact person
(
)
16.
Date you began or will begin selling or importing fuel into Idaho
17.
List all jurisdictions in which purchases or sales of fuel will take place.
18.
Provide a brief description of your operations within Idaho and other jurisdictions.
19.
Did you previously have a Withholding, Sales, Use, or Fuel tax permit with Idaho?
Yes
No
If yes, list all such numbers.
20.
Did you acquire an existing business?
Yes
No
If yes, list the previous business and owner's name.
21.
List (a) owner, spouse, (b) partners, or (c) corporate officers. (Use additional sheet if necessary.)
Name
Home Address
Social Security Number
Corporate
% of
Director?
Title
Ownership
For Department Use Only
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Parent category: Financial