Form R-5305 - Registration Application For Gasoline Blend Stocks
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2R-5305 (7/06)
Registration Application for
Gasoline Blend Stocks
Mail to:
Louisiana Department of Revenue
Taxpayer Services Division
Excise Tax Section
P.O. Box 66362
Baton Rouge, LA 70896-6362
(225) 219-7656 (225) 219-2114 (TDD)
PLEASE PRINT OR TYPE.
Legal Business or Corporation Name
Applicant’s FEIN/SSN
Date
Trade Name or DBA (if different from Business Name)
Contact Person
Applicant’s Physical Location (do not list P.O. Box)
City
State
ZIP
Mailing Address (if different from above)
City
State
ZIP
Telephone Number
Fax Number
E-Mail Address
LA Sales Tax Number
LA Corporation Tax Number
LA Motor Fuel Tax Number
Give a brief description of your business:
Explain how the gasoline blend stocks will be used:
If necessary, attach additional sheets.
FOR OFFICE USE ONLY
Name (Please print)
Account Number
Signature
Permit/Certificate Number
Date
By ________________________________
Date ____________
7689
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