Form Ap-178 - International Fuel Tax Agreement License Application Page 3
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4AP-178-3
(Rev.6-09/11)
TEXAS APPLICATION FOR INTERNATIONAL
FUEL TAX AGREEMENT (IFTA) LICENSE
Page 2
• Please read instructions
• TYPE OR PRINT
• Do not write in shaded areas
17. Legal name of owner (Same as Item 1)
•
18. Trade name (actual name under which your business operates)
Business number (Area code and number)
•
19. Location of your business (Use street and number or directions - NOT PO Box or Rural Route)
City
State
ZIP code
County
20. List International Registration Plan (IRP) number [This number can be obtained from your
•
cab card (Example: XXXXXXP1) or from the Texas Department of Transportation] .............................
•
21. If you do not have a Texas IRP number, list your Texas license plate number ......................................
•
22. If you do not have a Texas IRP number or a Texas license plate number, is your qualified motor vehicle leased? ............
YES
NO
•
If “YES,” does your lease agreement specify that you are the responsible party for filing reports and paying the fuel tax?
YES
NO
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23. List your U.S. DOT number .....................................................................................................................
24. Are you in a lease agreement and operating under another carrier's U.S. DOT number?
•
(See specific instructions for information about lease agreements.) .....................................................................................
YES
NO
NAME
DOT NUMBER
•
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If "YES", please list carrier's name and U.S. DOT Number .........
MONTH
DAY
YEAR
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25. Requested effective date for IFTA license ...........................................................................................................
26. IFTA decals will be issued for each of your qualified motor vehicles. Enter the number of motor vehicles requiring decals .........
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27. Have you ever been issued an IFTA license from a jurisdiction other than Texas? ..............................................................
YES
NO
If "YES," please list those jurisdictions and the year licensed
•
28. Has your IFTA license ever been suspended or revoked by a jurisdiction other than Texas? .............................................
YES
NO
If "YES," please list those jurisdictions
29. Types of fuels used by your qualified motor vehicles (
Check all that apply)
:
01 - Diesel
02 - Gasoline
03 - Ethanol
04 - Propane
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05 - CNG
06 - A-55
07 - E-85
08 - M-85
09 - Gasohol
10 - LNG
11 - Methanol
D
30. Indicate with a check (
) the jurisdictions in which you are operating, and in which you maintain bulk fuel storage
(OP-Operate; BF-Bulk Fuel Storage)
O P B F
O P B F
O P B F
O P B F
AL Alabama
KY Kentucky
NC North Carolina
WI Wisconsin
AK Alaska
LA Louisiana
ND North Dakota
WY Wyoming
AZ Arizona
ME Maine
OH Ohio
CANADIAN PROVINCES
AR Arkansas
MD Maryland
OK Oklahoma
CA California
MA Massachusetts
OR Oregon
AB Alberta
CO Colorado
MI
Michigan
PA Pennsylvania
BC British Columbia
CT Connecticut
MN Minnesota
RI
Rhode Island
MB Manitoba
DE Delaware
MS Mississippi
SC South Carolina
NB New Brunswick
DC Dist. of Columbia
MO Missouri
SD South Dakota
NF Newfoundland
FL
Florida
MT Montana
TN Tennessee
NT Northwest Territories
GA Georgia
NE Nebraska
TX Texas
NS Nova Scotia
ID
Idaho
NV Nevada
UT Utah
ON Ontario
IL
Illinois
NH New Hampshire
VT Vermont
PE Prince Edward Island
IN
Indiana
NJ New Jersey
VA Virginia
PQ Quebec
IA
Iowa
NM New Mexico
WA Washington
SK Saskatchewan
KS Kansas
NY New York
WV West Virginia
YT Yukon
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