Form Boe-400-Dc - California Interstate User Diesel Fuel Tax License Application For Corporations/limited Liability Companies/organizations Page 2

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BOE-400-DC (BACK) REV. 1 (9-03)

21. ARE YOU CURRENTLY UNDER LEASE TO ANOTHER CARRIER?

Carrier Name _________________________________________________________________

Yes (attach copy of lease)

If yes, please provide the information requested at the right:

Address _____________________________________________________________________

Interstate User Diesel Fuel Tax License or IFTA License

22. PRODUCTS GENERALLY HAULED

23. DATE OF FIRST INTERSTATE TRAVEL (month, day & year)

24. OTHER ACCOUNT NUMBERS ISSUED BY THIS BOARD TO THE APPLICANT OR ANY INDIVIDUAL NAMED IN SECTION I

SECTION III: VEHICLE INFORMATION

25. LIST COMPLETE INFORMATION FOR EACH OF YOUR QUALIFIED MOTOR VEHICLES (Please provide a photocopy of the registration document for each vehicle. Use additional sheet to include

information about additional vehicles.)

MAKE AND YEAR

ENGINE OR I.D. NUMBER

LICENSE NUMBER

TYPE OF FUEL USED

REGISTERED OWNER

LEGAL OWNER AND ADDRESS

SECTION IV: CERTIFICATION

I hereby certify that the statements contained in this application are correct to the best of my knowledge and belief, and that I am duly authorized to

sign this application.

Note: This form must be signed by a corporate officer, LLC member or manager, or by an authorized agent. For a corporation, attach authorizing

corporate resolution; and for an LLC, attach articles of organization that authorize the individual who signs below to certify this application. If signed

by an authorized agent, a properly completed power of attorney form/document must be attached to this application.

NAME (type or print)

TITLE

SIGNATURE

DATE

✍

CLEAR