Form Boe-400-Dc - California Interstate User Diesel Fuel Tax License Application
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2BOE-400-DC (FRONT) REV. 3 (7-06)
STATE OF CALIFORNIA
CALIFORNIA INTERSTATE USER DIESEL FUEL TAX LICENSE APPLICATION
BOARD OF EQUALIZATION
(CORPORATIONS/LIMITED LIABILITY COMPANIES/ORGANIZATIONS)
FOR BOARD USE ONLY
SECTION I: OwNERShIP INFORMATION
1. PLEASE CHECk TYPE OF OWNERSHIP
TAX
OFFICE
NUMBER
DI
MT
Corporation
Limited Liability Company (LLC)
Other
Enter Federal Employer Identification Number (FEIN), if any
2. ENTER FULL NAME OF CORPORATION, LIMITED LIABILITY CO. (LLC), OR ORGANIZATION
3. CORPORATE OR LLC NUMBER
4. STATE OF INCORPORATION OR ORGANIZATION
5. NUMERO DE CONSTITUCION DE SOCIEDAD (for corporations based in Mexico)
President
Vice President
Secretary
Treasurer
President
Vice President
Secretary
Treasurer
ChECK ONE
Manager
Member
Trustee
Beneficiary
Manager
Member
Trustee
Beneficiary
6. FULL NAME
(incl. mid. name)
7. ADDRESS
(home)
8. TELEPHONE
(
)
(
)
(home)
(attach copy)
(attach copy)
9. SOCIAL
SECURITY NO.
(or Mexican voter
registration no.)
(attach copy)
(attach copy)
10. DRIVER
LICENSE NO.
SECTION II: BUSINESS INFORMATION
11. BUSINESS OR TRADE NAME (DBA) (if any)
12. DEPARTMENT OF TRANSPORTATION NUMBER (DOT)
13. CERTIFICATE OF REGISTRATION FOR FOREIGN MOTOR CARRIERS (Mx Number) (for companies based in Mexico – attach copy)
14. BUSINESS ADDRESS (street, city, state, zip code – do not list P.O. Box, mailing service, or agent/bookkeeper’s address)
15. BUSINESS TELEPHONE NUMBER
(
)
16. MAILING ADDRESS (list complete address if different from No. 14 above – do not enter an agent/bookkeeper’s address, see No. 19 below)
17. AGENT/BOOkkEEPER’S NAME
18. AGENT/BOOkkEEPER’S TELEPHONE NUMBER
(
)
19. AGENT/BOOkkEEPER’S MAILING ADDRESS
Check this box to use agent/bookkeeper’s address for returns, notices, refund checks, bills, and all other correspondence
attach signed power of attorney
(
form)
20. NAME OF APPLICANT’S BANk OR OTHER FINANCIAL INSTITUTION
ACCOUNT NUMBER
LOCATION
(continued on back)
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Parent category: Legal