Form Rev-564 - Application For Pennsylvania Fuel Transporters Permit
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1
2REV-564 MF (12-13)
APPLICATION FOR
PENNSYLVANIA
FUEL TRANSPORTERS PERMIT
BUREAU OF MOTOR AND
ALTERNATIVE FUEL TAXES
YEAR
PO BOX 280646
START
HARRISBURG PA 17128-0646
V: 717.346.9416
F: 717.787.6261
FAILURE TO COMPLETE ALL SECTIONS WILL RESULT IN THE REJECTION OF APPLICATION
Section 9019 of the PA Liquid Fuels and Fuels Tax Act (Title 75 Chapter 90 - PA Motor Vehicle Code) requires anyone
importing, exporting or transporting fuels (clear diesel or kerosene) in Pennsylvania to register as a transporter and
report such deliveries to the Department of Revenue on a monthly basis. There is a $5 company registration fee for
this permit. Section 9015 also requires anyone delivering liquid fuels (gasoline, gasohol, aviation gasoline or jet fuel)
to file a monthly report showing such deliveries. These reports must be filed by common or contract carriers and by
companies delivering their own products.
1
Name under which the permit is to be issued (Legal Name(s), DBA or Fictitious Name)
Location of principal place of business (Description of exact location; P.O. Box is not acceptable)
2
Street
City or Town
County
State
ZIP Code
3
Mailing Address (if different than #2) P.O. Box or Street and Number
Street
City or Town
County
State
ZIP Code
4
Name, Title, Social Security number and home addresses of all individual owners and
elected officers constituting the Ownership, Partnership, Association or Corporation.
o
Require additional entries. See Page 2.
Name
NAME CAN BE PRINTED ON 2 LINES
Title
Social Security Number
Street Address
ADDRESS CAN BE PRINTED ON 2 LINES
City
State
ZIP Code
Email Address
FEIN
County Code
E-MAIL ADDRESS CAN BE PRINTED ON 2 LINES
Haul Via:
Business Telephone
Home Telephone
o
o
o
No. of
_______
Rail
Pipeline
Ship/Barge
Trucks
Fax Number
County Codes
Adams . . . . . . . . . . . 01
Chester . . . . . . . . . . 15
Fulton . . . . . . . . . . . 29
Mercer . . . . . . . . . . . 43
Somerset . . . . . . . . . 56
Allegheny . . . . . . . . . 02
Clarion . . . . . . . . . . . 16
Greene . . . . . . . . . . . 30
Mifflin . . . . . . . . . . . . 44
Sullivan . . . . . . . . . . 57
Armstrong . . . . . . . . 03
Clearfield . . . . . . . . . 17
Huntingdon . . . . . . . . 31
Monroe . . . . . . . . . . . 45
Susquehanna . . . . . . 58
Beaver . . . . . . . . . . . 04
Clinton . . . . . . . . . . . 18
Indiana . . . . . . . . . . . 32
Montgomery . . . . . . . 46
Tioga . . . . . . . . . . . . 59
Bedford . . . . . . . . . . 05
Columbia . . . . . . . . . 19
Jefferson . . . . . . . . . 33
Montour . . . . . . . . . . 47
Union . . . . . . . . . . . . 60
Berks . . . . . . . . . . . . 06
Crawford . . . . . . . . . 20
Juniata . . . . . . . . . . . 34
Northampton . . . . . . . 48
Venango . . . . . . . . . . 61
Blair . . . . . . . . . . . . . 07
Cumberland . . . . . . . 21
Lackawanna . . . . . . . 35
Northumberland . . . . 49
Warren . . . . . . . . . . . 62
Bradford . . . . . . . . . . 08
Dauphin . . . . . . . . . . 22
Lancaster . . . . . . . . . 36
Perry . . . . . . . . . . . . 50
Washington . . . . . . . . 63
Bucks . . . . . . . . . . . . 09
Delaware . . . . . . . . . 23
Lawrence . . . . . . . . . 37
Philadelphia . . . . . . . 51
Wayne . . . . . . . . . . . 64
Butler . . . . . . . . . . . . 10
Elk . . . . . . . . . . . . . . 24
Lebanon . . . . . . . . . . 38
Pike . . . . . . . . . . . . . 52
Westmoreland . . . . . . 65
Cambria . . . . . . . . . . 11
Erie . . . . . . . . . . . . . 25
Lehigh . . . . . . . . . . . 39
Potter . . . . . . . . . . . . 53
Wyoming . . . . . . . . . 66
Cameron . . . . . . . . . 12
Fayette . . . . . . . . . . . 26
Luzerne . . . . . . . . . . 40
Schuylkill . . . . . . . . . 54
York . . . . . . . . . . . . . 67
Carbon . . . . . . . . . . . 13
Forest . . . . . . . . . . . 27
Lycoming . . . . . . . . . 41
Centre . . . . . . . . . . . 14
Out of State . . . . . . . 99
Franklin . . . . . . . . . . 28
McKean . . . . . . . . . . 42
Snyder . . . . . . . . . . . 55
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