Form Dr-156r Draft - Renewal Application For Florida Fuel/pollutants License (Page 4 of 7) in pdf

DR-156R

R. 01/18

Page 3

Address where business records are maintained (cannot be a post office box)

10. Street address ___________________________________________________________________________________________

City ___________________________________ County _________________________ State _________ZIP ______________

Country ________________________________ Foreign postal code ______________________________________________

11. Mailing address __________________________________________________________________________________________

City ___________________________________ County _________________________ State _________ZIP ______________

Country ________________________________ Foreign postal code ______________________________________________

12. Parent corporation information (if applicable)

–

Parent corporation

FEIN

Phone number __________________________ Ext. _________________

Parent corporation name __________________________________________________________________________________

Parent corporation address _______________________________________________________________________________

Answer all questions. DO NOT leave any blank.

13. Owner, partner, officer information

List the primary owner or corporate officer first. Enter the name, social security number, home address and

telephone number of the owners, partners or corporate officers. Persons listed below who have not previously

undergone a background check must have one completed.

Applicants requesting a terminal supplier, importer, pollutants, exporter, blender, carrier, terminal operator,

wholesaler or retailer of natural gas fuels license must undergo a background check conducted by the Florida

Department of Law Enforcement (FDLE), the Federal Bureau of Investigations (FBI), and the Department of Revenue.

You must bring two forms of identification when you get your fingerprints scanned. One ID must have your picture

and signature, such as a driver license, state identification card or passport. You will also provide personal

information such as your full name, address, and social security number for the FBI to conduct the background

investigation.

You are responsible for paying all fees.

–

A) Name ___________________________________________________________ SSN

(Individual)

–

Home address ___________________________________________________ FEIN

(Business)

City ___________________________________________________ County ___________State ___________ZIP __________________

Country _________________________Foreign postal code _______ Phone Number ______________ Ext. ____________________

Corporate or business title __________________________________________________________ Interest/Ownership __________%

–

B) Name ________________________________________________ SSN

(Individual)

–

Home address __________________________________________FEIN

(Business)

City ___________________________ County _______________________ State ________________

ZIP ______

Country _______________ Foreign postal code ______________ Phone Number ________________

Ext. _____

Corporate or business title __________________________________________ Interest/Ownership ___________ %

–

C) Name ________________________________________________ SSN

(Individual)

–

Home address __________________________________________FEIN

(Business)

City ___________________________ County _______________________ State ________________

ZIP ______

Country _______________ Foreign postal code ______________ Phone Number ________________

Ext. _____

Corporate or business title __________________________________________ Interest/Ownership ___________ %

Form Dr-156r Draft - Renewal Application For Florida Fuel/pollutants License Page 4

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