Form Mvd-11213 - Application For Ifta License Renewal Form printable pdf download

State of New Mexico

MVD-11213

REV. 8/2002

Motor V

Motor Vehicle Division - Commercial V

ehicle Division - Commercial V

ehicle Division - Commercial Vehicle Bureau

ehicle Bureau

1100 South St. F

1100 South St. Francis Drive

rancis Drive

1100 South St. F

rancis Drive

PO Box 5188, Santa F

PO Box 5188, Santa Fe, NM 87504-5188

PO Box 5188, Santa F

e, NM 87504-5188

APPLIC

APPLICA A A A A TION FOR IFT

TION FOR IFT

TION FOR IFTA LICENSE RENEW

A LICENSE RENEW

A LICENSE RENEWAL

APPLIC

TION FOR IFT

A LICENSE RENEW

1. MTD No.

2. U.S. DOT No.

3. ICC No.

4. N.M. CRS No.

5. Legal Business Name

6. Federal Employer ID No.

7. DBA Name

8. State of Registration

9. Social Security No.

10.Physical Address (Business Location, Street or Rural Route, City, State, Zip Code)

11. Mailing Address (Street or Box Number, City, State, Zip Code)

12.Name of Person to Contact

13a. Telephone No.

13b. Fax No.

14.Type of Business (Fill in

)

Corporation

Sole Proprietor (No Employees)

LLC

S-Corporation

Sole Proprietor (With Employees)

Partnership

15.

LIST OWNERS, PARTNERS, SHAREHOLDERS OR THREE CORPORATE OFFICERS

Name

Social Security No.

Home Phone No.

(

)

Home Address, City, State, Zip Code

Name

Social Security No.

Home Phone No.

(

)

Home Address, City, State, Zip Code

Name

Social Security No.

Home Phone No.

(

)

Home Address, City, State, Zip Code

16.Bulk storage locations outside of New Mexico

17. F i l l i n ( ) for each Jurisdiction in which you travel.

A L

Alabama

K S

Kansas

V A

Virginia

N M

New Mexico

A K

Alaska

K Y

Kentucky

W A

Washington

N Y

New York

A Z

Arizona

L A

Louisiana

W V

West Virginia

N C

North Carolina

A R

Arkansas

M E

Maine

Wisconsin

N D

North Dakota

C A

California

M D

Maryland

W Y

Wyoming

O H

Ohio

C O

Colorado

M A

Massachusetts

A B

Alberta

O K

Oklahoma

C T

Connecticut

Michigan

B C

British Columbia

O R

Oregon

D E

Delaware

M N

Minnesota

M B

Manitoba

P A

Pennsylvania

D C

District of Columbia

M S

Mississippi

N B

New Brunswick

R I

Rhode Island

Florida

M O

Missouri

N F

Newfoundland

S C

South Carolina

G A

Georgia

M T

Montana

N S

Nova Scotia

S D

South Dakota

Idaho

N E

Nebraska

O N

Ontario

T N

Tennessee

I L

I l l i n o i s

N V

Nevada

Prince Edward Island

Texas

Indiana

N H

New Hampshire

P Q

Province of Quebec

U T

Utah

Iowa

N J

New Jersey

S K

Saskatchewan

V T

Vermont

18. Declaration

I declare that I have knowledge of the International Fuel Tax Agreement , t h a t I a c c e p t f u l l r e s p o n s i b i l i t y f o r a l l IFTA related taxes, that the

applicant is not licensed in another IFTA jurisdiction or had this license revoked in another IFTA jurisdiction and that all information is true,

correct and complete to the best of my knowledge. Applicant agrees to comply with reporting, payment, recordkeeping, and license display

requirements as specified in the International Fuel Tax Agreement . The applicant further agrees that the base jurisdiction may withhold any

refunds due if applicant is delinquent on payment of fuel taxes due any member jurisdiction. Failure to comply with these provisions shall be

grounds for revocation of license in all member jurisdictions.

Signature: _____________________________________________________________________

Date: _____________________________

Form Mvd-11213 - Application For Ifta License Renewal Form

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