Form Boe-400-Di - California Interstate User Diesel Fuel Tax License Application For Individuals/partnerships Page 2

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

26. PRODUCTS GENERALLY HAULED

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

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

SECTION III: VEHICLE INFORMATION

29. 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.

All owners’ signatures are required. If all partners are not available to sign, one may sign and attach a statement from the other general partners

authorizing that person to sign on their behalf.

NAME (type or print)

TITLE

SIGNATURE

DATE

NAME (type or print)

TITLE

SIGNATURE

DATE

CLEAR