Application For A Permit To Deliver Motor Fuels Into A Cargo Tank - Alabama Department Of Revenue

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P. O. Box 327556 • Montgomery, AL 36132-7556 • (334) 353-7827
Application For A Permit To Deliver Motor Fuels Into A Cargo Tank
As Provided By Act #93-628, Section 22-35-5, As Amended
(THIS APPLICATION DOES NOT CONSTITUTE A PERMIT)
APPLICANT’S NAME
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
TITLE
E-MAIL ADDRESS
FEIN
SSN
TELEPHONE NUMBER
–
OR
(
)
Indicate legal structure:
Individually owned
Partnership
Corporation
Limited Liability Co. (LLC)
Other ____________________
List below the names, identifying number (social security or FEIN number), and address of all owners, partners, corporate officers, and
LLC members. Attach additional sheets if space is not sufficient.
NAME
SSN/FEIN (Identifying #)
TITLE
HOME ADDRESS
If you are a LLC, are you a
single-member or
multi-member
For Federal income tax purposes, have you filed Internal Revenue Service (IRS) form 8832 electing to be treated as a corporation?
Yes
No
If yes, please attach a copy to this form.
COMPLETE THE REVERSE SIDE OF THIS APPLICATION
AFFIDAVIT
State _________________________ County ____________________________ I, _________________________________________
(NAME OF PERSON MAKING AFFIDAVIT)
the ___________________________________ of the _______________________________________________________________
(TITLE)
(NAME OF BUSINESS)
whose address is ________________________________________________________________________________ , first being duly
sworn, depose and say upon oath that the statement here submitted is full, true and correct to the best of my knowledge and belief.
Signature of affiant ______________________________________________________
Subscribed and sworn to before me this the __________ day of ____________________________ , ________
Signature of Notary Public ________________________________________________
My commission expires _________________________________________ , ________
Note: If you are a multi-member LLC, a separate affidavit must be completed by each member unless form TOB: LLC-AUTH1 is
completed authorizing a designated member.
OFFICE USE ONLY – APPROVAL FOR PERMIT
____________________________________________ _____________________ ____________________________
SUPERVISOR / MANAGER
EFFECTIVE DATE
PERMIT NUMBER

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