Form Dr-176 - Application For Air Carrier Fuel Tax License (Page 2 of 3) in pdf

Personnel/Partner Information: Full name, social security number (SSN), FEIN (if applicable), and address of each

DR-176

corporate officer, owner, general partner, stockholder with a controlling interest, and/or director. (You may make copies

R. 10/09

of this page if additional space is needed.)

–

A) Name ______________________________________________________

SSN

(Individual)

–

Home Address ______________________________________________

FEIN

(Business)

City _________________________

County _______________________________

State ____________

ZIP ___________

Country ________________

Foreign Postal Code ________________

Phone No. ___________________

Ext. ________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________%

–

B) Name ______________________________________________________

SSN

(Individual)

–

FEIN

Home Address ______________________________________________

(Business)

City _________________________

County _______________________________

State ____________

ZIP ___________

Country ________________

Foreign Postal Code ________________

Phone No. ___________________

Ext. ________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________%

–

C) Name ______________________________________________________

SSN

(Individual)

–

FEIN

Home Address ______________________________________________

(Business)

City _________________________

County _______________________________

State ____________

ZIP ___________

Country ________________

Foreign Postal Code ________________

Phone No. ___________________

Ext. ________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________%

–

D) Name ______________________________________________________

SSN

(Individual)

–

Home Address ______________________________________________

FEIN

(Business)

City _________________________

County _______________________________

State ____________

ZIP ___________

Country ________________

Foreign Postal Code ________________

Phone No. ___________________

Ext. ________

Corporate or Business Title _______________________________________________________ Interest/Ownership __________%

Note: Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida’s taxes.

SSNs obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as

public records. Collection of your SSN is authorized under state and federal law. Visit our Internet site at and select “Privacy

Notice” for more information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.

Affidavit of Applicant(s)

I, the undersigned individual(s), or if a corporation for itself, its officers, and directors, hereby swear or affirm under penalty of

perjury as provided in section 837.06, Florida Statutes, that I am duly authorized to make the foregoing application and that the

application and all attachments are true and correct representation(s) of the premises to be licensed. If licensed, I agree that the

place of business may be inspected and searched, during business hours or at any time business is being conducted on the

premises, by officials and agents of the Department of Revenue for the purposes of determining compliance with Chapter 206, F.S.

Sworn to (or affirmed) and subscribed before me

this ____________ day of ___________________ , ____________ .

State of _____________ County of ________________________________

__________________________________________

_________________________________________________________

Signature of Notary Public

Signature of Applicant

_________________________________________________________

Print or Type Applicant’s Name

W A R N I N G :

__________________________________________

Print, Type or Stamp Name of Notary

Personally Known __________

or Produced Identification __________

Read carefully: This instrument is a sworn document. False answers

could result in criminal prosecution subject to fine and/or imprisonment

Type of Identification Produced ___________________________________

and denial of your application.

Form Dr-176 - Application For Air Carrier Fuel Tax License Page 2

Related Articles

Related forms

Related Categories