Form Boe-400-Fta - Application For Fuel Tax/fee Account Number, License Or Permit
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3BOE-400-FTA (S1F) (8-01)
STATE OF CALIFORNIA
APPLICATION FOR FUEL TAX/FEE ACCOUNT NUMBER, LICENSE OR PERMIT
BOARD OF EQUALIZATION
SECTION I: TYPE OF ACCOUNT, LICENSE OR PERMIT
FOR BOARD USE ONLY
1. PLEASE CHECK TYPE OF ACTIVITY(S) YOU ARE ENGAGING IN:
TAX
OFFICE
NUMBER
Underground Storage Tank Account Number (TK)
Aircraft Jet Fuel Dealer Permit (MJ)
Vendor Use Fuel Tax Permit (AV)
User Use Fuel Tax Permit (AU)
Diesel Qualified Highway Vehicle Operator License (DH)
Train Operator License (PT)
Diesel Government Entity License (DG)
Oil Spill Response Fee Account Number (OR)
Exempt Bus Operator Diesel Fuel Tax License (DB)
Oil Spill Prevention, and Administration Fee Account Number (OA)
Vessel/Pipeline Operator License (PC)
Other
Industrial User License (PM)
PLEASE EXPLAIN YOUR BUSINESS OPERATIONS (attach additional sheets if necessary)
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
Other
2. DATE YOU WILL BEGIN ACTIVITIES REQUIRING A LICENSE, PERMIT OR ACCOUNT IN CALIFORNIA (month, day & year)
3. ENTER NAME OF PARTNERSHIP, CORPORATION, LIMITED LIABILITY COMPANY (LLC), ORGANIZATION, OR OTHER ORGANIZATION
4.Check here if you have included a
copy of your partnership agreement
5. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) OR SSN IF NO FEIN
6. CORPORATE OR LLC NUMBER, STATE OF INCORPORATION OR ORGANIZATION AND DATE OF INCORPORATION OR ORGANIZATION
Each owner, partner, corporate officer or principal must complete information below.
If needed, please attach additional sheet(s) to provide the information requested in this application.
Publicly traded companies are not required to complete this section.
President
Partner
Manager
Member
Owner
Trustee
7. FULL NAME (first, middle, last)
8. RESIDENCE ADDRESS (street, city, state, zip code)
9. SOCIAL SECURITY NUMBER (attach verification) (corporate officers excluded)
10. DRIVER LICENSE NUMBER (attach verification)
11. RESIDENCE TELEPHONE NUMBER
12. DAYTIME TELEPHONE NUMBER
(
)
(
)
13. SIGNATURE
Vice President
Co-Partner
Co-Manager
Member
Co-Owner
Trustee
14. FULL NAME (first, middle, last)
15. RESIDENCE ADDRESS (street, city, state, zip code)
16. SOCIAL SECURITY NUMBER (attach verification) (corporate officers excluded)
17. DRIVER LICENSE NUMBER (attach verification)
18. RESIDENCE TELEPHONE NUMBER
19. DAYTIME TELEPHONE NUMBER
(
)
(
)
20. SIGNATURE
Fuel Taxes/Fees Application
August 2001
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Parent category: Financial