BOE-400-DI (FRONT) REV. 1 (9-03)
STATE OF CALIFORNIA
CALIFORNIA INTERSTATE USER DIESEL FUEL TAX LICENSE APPLICATION
BOARD OF EQUALIZATION
(INDIVIDUALS/PARTNERSHIPS)
Use additional sheet(s) to include information for more than two partners.
SECTION I: OWNERSHIP INFORMATION
FOR BOARD USE ONLY
1. PLEASE CHECK TYPE OF OWNERSHIP
TAX
OFFICE
NUMBER
Sole Owner
Husband/Wife Co-ownership
DI
MT
Partnership
Enter Federal Employer Identification Number (FEIN), if any
OWNER OR PARTNER
2. FULL NAME (first, middle, last)
3. SOCIAL SECURITY NUMBER OR MEXICAN VOTER REGISTRATION NUMBER (attach copy)
4. DRIVER LICENSE NUMBER (attach copy)
5. RESIDENCE ADDRESS (street, city, state, zip code)
6. RESIDENCE TELEPHONE NUMBER
(
)
7. NAME, ADDRESS & TELEPHONE NUMBER OF A PERSONAL REFERENCE
CO-OWNER OR PARTNER
8. FULL NAME (first, middle, last)
9. SOCIAL SECURITY NUMBER OR MEXICAN VOTER REGISTRATION NUMBER (attach copy)
10. DRIVER LICENSE NUMBER (attach copy)
11. RESIDENCE ADDRESS (street, city, state, zip code)
12. RESIDENCE TELEPHONE NUMBER
(
)
13. NAME, ADDRESS & TELEPHONE NUMBER OF A PERSONAL REFERENCE
SECTION II: BUSINESS INFORMATION
14. BUSINESS OR TRADE NAME [DBA] (if any)
15. PARTNERSHIP NAME (if any)
16. DEPARTMENT OF TRANSPORTATION NUMBER (DOT)
17. CERTIFICATE OF REGISTRATION FOR FOREIGN MOTOR CARRIERS (MX Number) (for companies based in Mexico – attach copy)
18. BUSINESS ADDRESS (street, city, state, zip code – do not list P.O. Box, mailing service, agent/bookkeeper address)
19. BUSINESS TELEPHONE NUMBER
(
)
20. MAILING ADDRESS (list complete address if different from No. 18 above – do not enter an agent/bookkeeper address, see 23 below)
21. AGENT/BOOKKEEPER NAME
22. AGENT/BOOKKEEPER TELEPHONE NUMBER
(
)
23. AGENT/BOOKKEEPER MAILING ADDRESS
Check this box to use agent/bookkeeper address for returns, notices, refund checks, bills, and all other correspondence
(attach signed power of attorney form)
24. NAME OF APPLICANT’S BANK OR OTHER FINANCIAL INSTITUTION
ACCOUNT NUMBER
LOCATION
25. ARE YOU CURRENTLY UNDER LEASE TO ANOTHER CARRIER?
Carrier Name
No
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