Form Dr-166 - Florida Pollutant Tax Application - 2003
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2DR-166
Florida Pollutant Tax Application
R. 08/03
Mail this application with $30 fee to:
For DOR Use Only
CENTRAL REGISTRATION
License Number
FLORIDA DEPARTMENT OF REVENUE
PO BOX 6480
TALLAHASSEE FL 32314-6480
Approval Date
Examiner’s Initials
1.
Business Name: _________________________________________________________________________________________
2.
Owner’s Name: _________________________________________________________________________________________
(Individual, Corporation, Partnership, Limited Liability Company)
Federal Employer
3.
Identification Number:
For DOR use only - Do not write in this space.
4.
Location Address: ____________________________________________________
(Street Address)
___________________________________________________________________
(City)
(State)
(ZIP)
5.
Mailing Address: _____________________________________________________
(Street Address)
(if other than location address)
___________________________________________________________________
(City)
(State)
(ZIP)
6.
Type of Organization:
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■ ■
■ ■
Individual Proprietorship
Corporation
Partnership
■ ■
Limited Liability Company
7.
Corporate or Partnership Information (If you are an individual proprietor, do not complete this section):
Home Address
Percent Business Interest
Social Security Number
Name*
(Include City, State, ZIP)
or Corporate Title
*Full name of corporate officers, partners, directors, and stockholders with a controlling interest
(attach separate sheets if necessary)
8.
Contact Person’s Name: _______________________________ 9.
Contact Person’s Phone: (_______) __________________
Contact Person’s Fax:
(_______) __________________
■ ■
10. Type of Application:
New Applicant/Business
Date Business Began or Will Begin: ____________________________
■ ■
Legal Entity Change
Date of Change: ___________________________________________
Previous Pollutants License Number: ____________________________________________________
11. This business will (check appropriate box(es)):
■ ■
■ ■
■ ■
Produce
Import or cause to be imported (into Florida)
Export
■ ■
Be entitled to a refund on the following taxable pollutants:
■ ■
■ ■
■ ■
■ ■
Petroleum Products
Ammonia
Pesticides
Chlorine
■ ■
■ ■
■ ■
■ ■
Motor Oil or Other Lubricants
Crude Oil
Solvents
Perchloroethylene
■ ■
Other (specify) ________________________________________________________________________________
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