Application For An Alabama Aviation License - Alabama Department Of Revenue

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A
D
R
SUBT: AVLA
LABAMA
EPARTMENT OF
EVENUE
Reset
8/11
B
& L
T
D
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 Aviation License
(THIS APPLICATION DOES NOT CONSTITUTE A LICENSE.)
Under the provisions of Title 40, Chapter 12, Article 3, Code of Alabama 1975, I hereby make application for a license to engage in the distribution, sale, withdrawal or use of
aviation fuels 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 license, I shall, for myself or firm, association, co-partnership or corporation I represent, comply with the aviation fuels excise tax laws in every particular.
COMPANY NAME (AS WILL APPEAR ON LICENSE)
STREET ADDRESS
CITY
COUNTY
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
$
5.00
A fee of
Failure to answer all questions or provide the requested documents
and a certified financial statement
will constitute cause for the rejection of your application by the
Alabama Department of Revenue.
must accompany 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
under penalties of perjury 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
FOR OFFICE USE ONLY
The above application is subject to
posting of bond in the sum of $________________________ .
License will be issued only when bond is posted and approved.
MANAGER, MOTOR FUELS SECTION
DATE

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