Form Dr-156r Draft - Renewal Application For Florida Fuel/pollutants License Page 3
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7DR-156R
R. 01/18
Page 2
This application must be completed in its entirety along with the appropriate attachments and be approved by the Florida Department
. WARNING: It is a third-degree felony to operate without a license.
of Revenue prior to December 31
st
-
1. Federal employer identification number (FEIN)
FEIN:
or
-
-
Social security number (SSN), if FEIN is not available
SSN:
2. Business Name ________________________________________ Phone number____________________________________
3. Trade name, DBA or AKA __________________________________ Fax number ___________________________________
4. Contact person ______________________________________ Phone number _________________________Ext. _______
5. Contact Email Address ___________________________________________________________________________________
6. Type and legal organization: (Please check only one)
A)
Corporation (check one):
C Corp
S Corp
If corporation, check any of the appropriate boxes that apply:
Publicly held corporation *
Privately held corporation
Wholly owned subsidiary of a publicly held corporation
B)
Partnership (check one):
General
Limited
Joint Venture
C)
Limited liability company (check one):
Single member
Multi-member
check here if you elected to be treated as a corporation for federal income tax puposes
D)
Individual/Sole Proprietorship
E)
Business Trust
F)
Governmental Agency
* Publicy held corporations must attach Federal Form 10K or the most recent annual report documenting publicly
held status.
7.
Principal business location address: (cannot be a post office box) _____________________________________________
________________________________________________________________________________________________________
City ______________________________ County __________________________ State _________ ZIP ______________
Country _____________________________________ Foreign postal code ________________________________________
8. Please check each box that applies to your business activity.
Wholesaler
Terminal Supplier
Private Carrier
Common Carrier
Air Carrier
Exporter
Terminal Operator
Blender
Importer
Pollutants
Retailer of Natural Gas
9. A) If you are a terminal operator, have you changed the location of or added any terminals?
YES
NO
B) If “YES,” state the number of terminals: ___________and complete the following information for each terminal
location address you operate. Attach additional sheets if necessary.
Terminal Location
Address _______________________________________________________________________________________
City ________________________________________ State ______ZIP _____________________
Phone Number ______________________________
Terminal Location
Address _______________________________________________________________________________________
City ________________________________________ State ______ZIP _____________________
Phone Number ______________________________
Terminal Location
Address _______________________________________________________________________________________
City ________________________________________ State ______ZIP _____________________
Phone Number ______________________________
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