Form Ap-178 - International Fuel Tax Agreement License Application (Page 4 of 4) in pdf

AP-178-4

(Rev.6-09/11)

TEXAS APPLICATION FOR INTERNATIONAL

FUEL TAX AGREEMENT (IFTA) LICENSE

Page 3

• Please read instructions

• TYPE OR PRINT

• Do not write in shaded areas

31. Legal name of owner (Same as Item 1)

•

32. Legal name of authorized agent/representative

•

33. Mailing address

City

State

ZIP code

Business number

(Area code & number)

Date of application

34. The sole owner, all general partners, corporation president, vice-president, secretary or treasurer or an

month

day

year

authorized agent must sign this application. Representatives must submit a written power of attorney with

application. (Attach additional sheets if necessary.)

Bonds are not generally required of first-time applicants. However, a bond may be required if an IFTA licensee has a history of not filing tax

returns on time, not remitting tax due, or other problems severe enough to indicate that a bond is required to protect the interests of all

member jurisdictions.

The applicant agrees to comply with reporting, payment, record keeping and license and decal display requirements as specified in the

International Fuel Tax Agreement. The applicant further agrees that Texas 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.

I (We) certify that the information in this document and any attachment is true, accurate and complete to the best of my (our) knowledge. I

(We) acknowledge that any falsification of document information subjects me (us) to civil and/or criminal sanctions of the State of Texas.

Type or print name and title of sole owner, partner, officer or authorized agent

Sole owner, partner, officer or authorized agent

Type or print name and title of partner or officer

Partner or officer

Type or print name and title of partner or officer

Partner or officer

WARNING: You may be required to obtain an additional permit or license from the State of Texas or from a local governmental entity

to conduct business. A listing of links relating to acquiring licenses, permits, and registrations from the State of Texas is available

online at You may also want to contact the municipality and county in which you will

conduct business to determine any local governmental requirements.

Form Ap-178 - International Fuel Tax Agreement License Application Page 4