Application For An Alabama Lubricating Oils Permit - Alabama Department Of Revenue

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A
D
R
SUBT: LOAP
LABAMA
EPARTMENT OF
EVENUE
8/11
B
& L
T
D
Reset
USINESS
ICENSE
AX
IVISION
M
F
S
OTOR
UELS
ECTION
P. O. Box 327540 • Montgomery, AL 36132-7540 • (334) 242-9608 • Fax (334) 242-1199
Application For An Alabama Lubricating Oils Permit
(THIS APPLICATION DOES NOT CONSTITUTE A LICENSE.)
Under the provisions of Title 40, Chapter 17, Article 4, Code of Alabama 1975, I hereby make application for a permit to engage in the distribution, sale, withdrawal or use of
lubricating oils in Alabama, subject to all the laws governing this privilege, and such rules and regulations as may be promulgated by the Alabama Department of Revenue. If
granted a permit, I shall, for myself, or for any corporation or agency that I represent, comply with the lubricating oils excise tax laws in every particular.
APPLICANT’S NAME (AS WILL APPEAR ON PERMIT)
STREET ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS
CITY
STATE
ZIP CODE
SOCIAL SECURITY NUMBER
FEDERAL IDENTIFICATION NUMBER
TELEPHONE NUMBER
CONTACT PERSON
E-MAIL ADDRESS
(
)
Indicate legal structure:
Individually owned
Partnership
Corporation
LLC
Other: ____________________________________________
State of incorporation/organization: ____________________________________
If LLC, have you elected to be taxed as a corporation under federal income tax laws?
Yes
No. If yes, please attach a copy of the election form.
List below names, titles, social security numbers and legal addresses of owner, partners or corporate officers, or LLC members. (Attach a listing if necessary.)
NAME
NAME
NAME
TITLE
TITLE
TITLE
SOCIAL SECURITY NO.
SOCIAL SECURITY NO.
SOCIAL SECURITY NO.
ADDRESS
ADDRESS
ADDRESS
COMPLETE THE REVERSE SIDE OF THIS APPLICATION.
Failure to answer all questions or provide the requested documents
will constitute cause for the rejection of your application by the Alabama Department of Revenue.
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 _____________________________ , 20_____ .
My commission expires _______________________ , 20_____ .
SIGNATURE OF NOTARY PUBLIC
OFFICE USE ONLY – APPROVAL FOR PERMIT
Permit will be issued upon approval by Manager.
______________________________________________
______________________________________________
MANAGER, MOTOR FUELS SECTION
EFFECTIVE DATE
Forms Needed
LO
WOL
LOX

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