Form Ap-178 - International Fuel Tax Agreement License Application Page 2
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4AP-178-2
(Rev.6-09/11)
TEXAS APPLICATION FOR INTERNATIONAL
FUEL TAX AGREEMENT (IFTA) LICENSE
Page 1
• Please read instructions
• TYPE OR PRINT
• Do not write in shaded areas
1. Legal name of owner (Sole owner, partnership, corporation or other name)
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2. Mailing address (Street and number, P.O. box or rural route and box number)
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City
State
ZIP code
County
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3. Enter the name and daytime phone number of the person primarily responsible for filing tax returns
(
)
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4. Enter your Federal Employer’s Identification (FEI) number, if any,
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assigned to the owner entered in Item 1 ........................................................................................
5. Enter your Social Security Number (SSN) if you are a sole owner ....................................................
6.
Check here if you do not have either FEI or SSN
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7. Enter your taxpayer number for reporting any Texas tax OR your Texas
Vendor Identification Number if you now have or have ever had one ...............................................
(Submit a copy of trust
8. Indicate how your business is owned.
Sole owner
Partnership
Texas corporation
Trust
agreement with application.)
Foreign corporation
Limited partnership
Other (explain)
Charter number
Charter date
9. If your business is a Texas corporation,
enter the charter number and date .......................................................
10. If your business is a foreign corporation, enter home state, charter number, Texas Certificate of Authority number and date.
Home state
Charter number
Texas Certificate of Authority number
Texas Certificate of Authority date
Home state
Partnership Date
Identification number
11. If your business is a limited partnership, enter the home state,
the partnership date and identification number ........................
12. List all general partners or principal officers of your business. (Attach additional sheets, if necessary.) If you are a sole owner, skip Item 12.
Name (First, middle initial, last)
Social Security or Federal Employer's Identification (FEI) no.
Title
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Home address (Street and number, city, state, ZIP code)
Phone (Area code and number)
Name (First, middle initial, last)
Social Security or Federal Employer's Identification (FEI) no.
Title
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Home address (Street and number, city, state, ZIP code)
Phone (Area code and number)
Name (First, middle initial, last)
Social Security or Federal Employer's Identification (FEI) no.
Title
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Home address (Street and number, city, state, ZIP code)
Phone (Area code and number)
If you purchased an existing business or business assets, complete Items 13-16. If you did not, skip to Item 17.
13. Enter the former owner's trade name. If known, enter the former owner's Texas taxpayer number.
Trade name
Taxpayer number of former owner
14. Enter the former owner's legal name. If known, enter the former owner's address and telephone number.
Legal name of former owner
Phone (Area code and number)
Address of former owner (Street and number, city, state, ZIP code)
15. Check each of the following items you purchased.
Inventory
Corporate stock
Equipment
Real estate
Other assets
16. Enter the purchase price of the business or assets purchased and the date of purchase.
Purchase price
Date of purchase
$
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