Fillable Form Tc-107 - Fuel License Application (Page 2 of 3) in pdf

Form Tc-107 - Fuel License Application Page 2

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General Information

Social Security Number (for sole proprietor)

Employer Identification Number (EIN)

Type of ownership

(must check one)

County code

Office

artnership

use only

ole/Individual Proprietor

imited Liability Company

orporation

artnership - Limited

Day telephone number

Owner’s name (if the owner is a business entity, write the entity’s registered name here)

DBA/Business name (complete Officer(s), Owner(s), or Partner(s) information below)

City

State

Zip code

Physical or street address

P.O. Box not acceptable

Mailing address (Write "same" if same as physical address)

City

State

Zip code

Officer(s), Owner(s), or Partner(s) Attach additional pages if needed

Social Security Number or

Effective

Names of officer(s), owner, or partner(s)

Address

Telephone

Federal Identification Number

date

Street

City

State

ZIP code

Street

City

State

ZIP code

Street

City

State

ZIP code

Street

City

State

ZIP code

Street

City

State

ZIP code

Street

City

State

ZIP code

Street

City

State

ZIP code

Street

City

State

ZIP code

Street

City

State

ZIP code

I certify that this application, including all accompanying pages, have been examined by me and to the best of my knowledge is true, accurate and

complete. Any person who has the authority to direct collecting, accounting, withholding and/or paying taxes may be held liable for a penalty equal to

taxes not paid to the State of Utah. Utah Code 59-1-302.

Signature of Authorized Applicant or Owner

Date signed

Title

Authorized signatures required: (Application cannot be accepted without original signature)

Sole Proprietor - The sole proprietor/owner.

Corporation - Any officer or registered agent authorized by the corporation.

General Partnership - Any general partners.

Limited Liability Partnership (LLP) - Any general partner authorized by the LLP.

Limited Partnership - Any general partner.

Limited Liability Company (LLC) - Any member or manager authorized by the LLC.

Business Trust - The trustee/beneficiary.