Form Boe-400-Fco - Supplier And/or Ultimate Vendor Fuel Tax License Application - Board Of Equalization - California
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2BOE-400-FCO (FRONT) REv. 5 (11-07)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
SUPPLIER AND/OR ULTIMATE VENDOR
FUEL TAX LICENSE APPLICATION
SECTION I: TYPE OF LICENSE
FOR BOARD USE ONLY
1. PLEASE CHECK TYPE OF BUSINESS OPERATIONS YOU ARE ENGAGING IN AND DESCRIBE BELOW:
TAX
OFFICE
NUMBER
(see page 7 for definitions)
Terminal Operator
Blender
Ultimate vendor (Diesel Fuel Only)
Position Holder
Enterer
Refiner
Throughputter
PLEASE DESCRIBE YOUR BUSINESS OPERATIONS (attach additional sheets if necessary)
2. CHECK TYPES OF FUEL REMOvED, ENTERED, OR SOLD
Gasoline
Diesel
Dyed Diesel
Aviation Gasoline
Other Please explain
SECTION II: OWNERSHIP INFORMATION
1. PLEASE CHECK TYPE OF OWNERSHIP
Sole Owner
General Partnership (provide a copy of your partnership agreement)
Limited Partnership
Husband/Wife Co-Ownership
(provide a copy of your partnership agreement)
Limited Liability Company (LLC)
Corporation
Business Trust
Joint venture
Registered Domestic Partnership
Other
2. DATE YOU WILL BEGIN ACTIvITIES REQUIRING A LICENSE IN CALIFORNIA (month, day & year)
(include a copy of your partnership agreement
3. ENTER NAME OF PARTNERSHIP, CORPORATION, LIMITED LIABILITY COMPANY (LLC), ORGANIZATION, OR OTHER
or LLC agreement)
4. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) OR SSN IF NO FEIN
5. CORPORATE OR LLC NUMBER
6. STATE OF INCORPORATION OR ORGANIZATION
7. DATE OF INCORPORATION OR ORGANIZATION
Each owner, partner, corporate officer or principal must provide the information requested below.
If needed, please attach additional sheet(s) to provide the information requested in this application.
Officers of publicly traded companies are not required to complete this section.
President
Partner
Registered Domestic Partner
Manager
Member
Owner
Trustee
8. FULL NAME (first, middle, last)
9. RESIDENCE ADDRESS (street, city, state, zip code)
10. SOCIAL SECURITY NUMBER (attach verification) (corporate officers excluded)
11. DRIvER LICENSE NUMBER (attach verification)
12. RESIDENCE TELEPHONE NUMBER
13. DAYTIME TELEPHONE NUMBER
(
)
(
)
14. SIGNATURE
-
vice President
Co-Partner
Registered Domestic Partner
Co-Manager
Member
Co-Owner
Trustee
15. FULL NAME (first, middle, last)
16. RESIDENCE ADDRESS (street, city, state, zip code)
17. SOCIAL SECURITY NUMBER (attach verification) (corporate officers excluded)
18. DRIvER LICENSE NUMBER (attach verification)
19. RESIDENCE TELEPHONE NUMBER
20. DAYTIME TELEPHONE NUMBER
(
)
(
)
21. SIGNATURE
-
Secretary
Co-Partner
Registered Domestic Partner
Co-Manager
Member
Co-Owner
Trustee
22. FULL NAME (first, middle, last)
23. RESIDENCE ADDRESS (street, city, state, zip code)
24. SOCIAL SECURITY NUMBER (attach verification) (corporate officers excluded)
25. DRIvER LICENSE NUMBER (attach verification)
26. RESIDENCE TELEPHONE NUMBER
27. DAYTIME TELEPHONE NUMBER
(
)
(
)
28. SIGNATURE
-
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