Form Boe-400-Fco - Application For Supplier And/or Ultimate Vendor Fuel Tax License Page 2
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2BOE-400-FCO (BACK) REV. 1 (4-01)
SECTION III: BUSINESS INFORMATION
1. CURRENTLY DOING BUSINESS AS [DBA] ( write none if not applicable) Partnerships complete if business name different than name of partnership.
2. BUSINESS ADDRESS (do not list P.O. Box or mailing service) If two or more locations, please attach a list. TELEPHONE NUMBER
FAX NUMBER
(
)
(
)
3. MAILING ADDRESS (if different from above) (street, city, state, zip)
4. ADDRESS WHERE BOOKS AND RECORDS ARE MAINTAINED (street, city, state, zip)
TELEPHONE NUMBER
FAX NUMBER
(
)
(
)
5. NAME OF PERSON TO CONTACT REGARDING ALL LICENSING ACTIVITIES
TELEPHONE NUMBER
FAX NUMBER
(
)
(
)
6. NAME OF PERSON TO CONTACT REGARDING TAX REPORTING ACTIVITIES
TELEPHONE NUMBER
FAX NUMBER
(
)
(
)
7. NAME OF BANK OR FINANCIAL INSTITUTION HOLDING BUSINESS PRIMARY ACCOUNT
ACCOUNT NUMBER
ADDRESS (mailing address, city, state, zip)
TELEPHONE NUMBER
FAX NUMBER
(
)
(
)
8. DO YOU OWN, OPERATE OR OTHERWISE CONTROL A TERMINAL?
Yes
No If yes, state the number of terminals:
and complete the following information for each terminal location. (If more than one
location, please attach a list.)
TERMINAL LOCATION ADDRESS (city, state)
CAPACITY OF TANKS
9. DO YOU HAVE A LETTER OF REGISTRATION NUMBER, (IRS) FORM 637 FOR EACH TERMINAL LOCATION?
Yes
No If yes, attach copy.
10. DO YOU HAVE OTHER BOARD OF EQUALIZATION ISSUED LICENSES OR PERMITS?
Yes
No If yes, please list the account numbers.
11. ARE YOU BUYING A BUSINESS?
Yes
No If yes, please list seller’s name and fuel tax account number(s) if known.
12. ARE THERE UNDERGROUND STORAGE TANK(S) AT THE CALIFORNIA BUSINESS LOCATION?
Yes
No If yes, are you the owner?
Yes
No
If yes, please provide your account number TK MT 44
-
If no, please provide name and address of the owner of the tank.
13. ESTIMATED AVERAGE MONTHLY GALLONS
Motor Vehicle Fuel
Diesel Fuel
Total removals, entries, or sales
gallons
Total removals, entries, or sales
gallons
Minus exempt removals, entries, or sales
gallons
Minus exempt removals, entries, or sales
gallons
Total taxable removals, entries, or sales
gallons
Total taxable removals, entries, or sales
gallons
SECTION IV: CERTIFICATION
I certify and declare, under penalty of perjury, that the information contained herein is correct to
the best of my knowledge and that I am authorized to sign and certify this application.
NAME (typed or printed)
TITLE
SIGNATURE
DATE
Return Application to: Board of Equalization, Fuel Industry Section,
450 N Street, P.O. Box 942879 MIC:30, Sacramento, CA 94279-0030, 916-322-9669
FOR BOARD USE ONLY
SECURITY REVIEW
RETURNS
PUBLICATIONS
BOE-598 $
No Security
FURNISHED TO TAXPAYER
License Issued Date
PUB 6
PUB 14
REPORTING BASIS
PUB 19
PUB 70
Monthly
Yearly
Monthly Prepay
Quarterly
EFT
BY
APPROVED BY
CLEAR
PRINT
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