International Fuel Tax Agreement Application Form - 2014
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1
2INTERNATIONAL FUEL TAX AGREEMENT APPLICATION
DEPARTMENT OF TRANSPORTATION
5300 BISHOP BOULEVARD
CHEYENNE, WYOMING 82009-3340
(307) 777-4827
$10.00
$3.00
SET
A
LICENSE FEE PLUS
PER
OF DECALS
.
:
MUST BE REMITTED WITH THIS APPLICATION
MAKE CHECK OR MONEY ORDER PAYABLE TO THE
.
WYOMING DEPARTMENT OF TRANSPORTATION
I
,
,
F THERE IS ANY CHANGE IN COMPANY NAME
CORPORATE OFFICERS
ARTICLES OF INCORPORATION OR COMPANY ENTITY THAT
F
E
I
N
(FEIN)
RESULTS IN THE ISSUANCE OF A NEW
EDERAL
MPLOYER
DENTIFICATION
UMBER
YOU MUST CANCEL YOUR ORIGINAL
,
FEIN
$10.00
. P
ACCOUNT
REAPPLY UNDER THE NEW NAME AND
AND REMIT THE REQUIRED
LICENSE FEE
LEASE CONTACT US AT
. I
THE NUMBER ABOVE FOR A NEW APPLICATION
F YOU HAVE EXPERIENCED A CHANGE IN ADDRESS OR TELEPHONE NUMBER PLEASE
D
, ATTN: M
V
S
, IFTA S
.
SEND WRITTEN NOTICE TO THE
EPARTMENT
OTOR
EHICLE
ERVICES
ECTION
FAILURE TO COMPLETE ALL OF THE INFORMATION BELOW MAY DELAY THE PROCESSING OF YOUR
CREDENTIALS
#’
-
- (
) ________________________
FEIN
FEDERAL EMPLOYER IDENTIFICATION NUMBER
NO SOCIAL SECURITY
S ACCEPTED
(
)
FEIN MUST MATCH LEGAL NAME
NAME (SAME AS FEDERAL DOT #) __________________________________________________________________
DBA
_____________________________________________________________________________________________
(
)
NAME UNDER WHICH BUSINESS IS CONDUCTED
:
( )
( )
( )
LLC ( )
TYPE OF OWNERSHIP
INDIVIDUAL
PARTNERSHIP
CORPORATION
____________________________
N
____________________________
BUSINESS TELEPHONE NUMBER
BUSINESS FAX
UMBER
_________________________________
________________________
NAME OF CONTACT
PHONE NUMBER OF CONTACT
___________________________________________________________________________
CONTACT EMAIL ADDRESS
_______________________________
______________________STATE______
____________
PHYSICAL ADDRESS
CITY
ZIP
________________________________
______________________STATE______
___________
MAILING ADDRESS
CITY
ZIP
,
IF YOU LEASE TO ANOTHER COMPANY
THAT COMPANY’S
.
.
_______________________
_________________________________
U
S
DOT NUMBER
DOT NUMBER
IDENTIFY OWNERS, PARTNERS, OR CORPORATE OFFICERS (IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL SHEETS):
NAME
TITLE
ADDRESS
PLEASE TURN OVER AND COMPLETE BACK PAGE
10.14
MVS
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