Form Rev-564 - Application For Pennsylvania Fuel Transporters Permit Page 2
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1
2For whom do you haul?
o
Self
o
Other (Name up to three below.)
1.
2.
3.
5
Have you, any partner or a corporation in which you or any other partner had greater than 5 percent
interest, ever been revoked as a licensee or convicted of a motor fuel tax-related violation?
o
o
NO
YES
If yes, indicate jurisdiction(s) in which action(s) occurred:__________________, and the
MM/DD/YYYY
date(s) of the action(s) ___________________________.
6
I certify the information provided on this form has been examined by me and is, to the best of my
knowledge, true and correct.
NAME CAN BE PRINTED ON 2 LINES
PRINT NAME
SIGNATURE
PLEASE SIGN AFTER PRINTING
MM/DD/YYYY
TITLE
DATE
4
Additional entries. (Attach a separate sheet if more space is required.)
Name
Title
Social Security Number
Street Address
City
State
ZIP Code
Email Address
FEIN
County Code
Haul Via:
Business Telephone
Home Telephone
o
o
o
No. of
_______
Rail
Pipeline
Ship/Barge
Trucks
Fax Number
Name
Title
Social Security Number
Street Address
City
State
ZIP Code
Email Address
FEIN
County Code
Haul Via:
Business Telephone
Home Telephone
o
o
o
No. of
_______
Rail
Pipeline
Ship/Barge
Trucks
Fax Number
Name
Title
Social Security Number
Street Address
City
State
ZIP Code
Email Address
FEIN
County Code
Haul Via:
Business Telephone
Home Telephone
o
o
o
No. of
_______
Rail
Pipeline
Ship/Barge
Trucks
Fax Number
Reset Entire Form
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