Form Crf-Ifta - Ifta Motor Carrier Registration Application Page 2
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CRF-IFTA (10/10)
GEORGIA DEPTARTMENT OF REVENUE
PROCESSING CENTER - MOTOR VEHICLE/IFTA
P.O. BOX 740382
ATLANTA, GA 30374-0382
404-968-3800
21.
OPERATING JURISDICTIONS
Complete the schedule below by placing an “X” next to the jurisdictions in which you plan to maintain bulk storage of fuel.
RI
Rhode Island
AK
Alaska
IL
Illinois
NC
North Carolina
SC
South Carolina
AL
Alabama
IN
Indiana
ND
North Dakota
SD
South Dakota
AR
Arkansas
KS
Kansas
NE
Nebraska
TN
Tennessee
AZ
Arizona
KY
Kentucky
NH
New Hampshire
LA
Louisiana
TX
Texas
CA
California
N J
New Jersey
CO
Colorado
MA
Massachusetts
NM
New Mexico
UT
Utah
VA
Virginia
CT
Connect icut
MD
Maryland
NV
Nevada
VT
Vermont
DC
District of Columbia
ME
Maine
NY
New York
WA
Washington
DE
Delaware
MI
Michigan
OH
Ohio
MN
Minnesota
WI
Wisconsin
FL
Florida
OK
Oklahoma
GA
Georgia
MO
Missouri
OR
Oregon
WV
West Virginia
WY
Wyoming
IA
Iowa
MS
Mississippi
PA
Pennsylvania
ID
Idaho
MT
Montana
CANADIAN PROVINCES
AB
Alberta
MB
M anitoba
PE
Prince Edward Island
NS
Nova Scotia
BC
British Columbia
NB
New Brunswick
PQ
Quebec
NT
N W Territory
NF
New Foundland and Labrador
SK
Saskatchewan
ON
Ontario
YT
Yukon Territory
OWNERSHIP/RELATIONSHIP SECTION
(This section MUST be completed for your application to be accepted) (Continued on page 3)
:
22.
GEORGIA IFTA EFFECTIVE DATE
CHECK ALL THAT APPLY
/
/
Manager
Related Business
Owner
Parent Company
Partner
Officer
Other
A
BUSINESS NAME
STI or LICENSE NO.
B
GA. SALES TAX NO.
GA. WITHHOLDING TAX NO.
M.I.
TITLE
SOC SEC NO.
C
LAST NAME
FIRST
(Required)
D
ADDRESS
E
CITY
STATE
ZIP
COUNTY
COU NTR Y
PHONE
(
)
Revision Date CRF-IFTA (10/10)
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