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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TC-107.ai Rev. 6/05

General Information

Employer Identification Number (EIN)

Social Security Number (for sole proprietor)

Type of ownership

(If you are a married partnership, check the “Sole/Individual Proprietor” box and provide both names

County code

in the Officer(s), Owner(s) or Partner(s) section below)

Office

artnership

use only

ole/Individual Proprietor

imited Liability Company

orporation

artnership - Limited

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

Daytime telephone number

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

Physical or street address

City

State

Zip code

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

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

Address

Telephone

Employer 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, has 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

Title

Date signed

Authorized signature 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 partner

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