Form Dr-156 - Florida Fuel Or Pollutants Tax Application Page 4

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Florida Fuel or Pollutants Tax Application
DR-156
R. 01/18
Page 1
–
1.
Federal Employer Identification Number (FEIN)
FEIN
2.
Business Name ___________________________________________________________ Phone No. __________________________
3.
Trade Name, D.B.A. or A.K.A. _______________________________________________ Fax No. _____________________________
4.
Contact Person ___________________________________________________________ Phone No. _______________ ext. ______
5.
Contact Email Address ____________________________________________________
6.
Type and Legal Organization: (Please check only one)
A) o Corporation (check one): o C Corp o S Corp
If corporation, check any of the appropriate boxes that apply:
o Publicly Held Corporation* o Privately Held Corporation
o Wholly Owned Subsidiary of a Publicly Held Corporation
B) o Partnership (check one): o General o Limited o Joint Venture
C) o Limited Liability Company (check one): o Single Member o Multi-member
D) o Individual/Sole Proprietorship
E) o Business Trust
F) o Governmental Agency
* Publicly 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.
How would your company like to receive information on Florida fuel or pollutants tax? (Please check one)
o Mail
(U.S. Postal Service)
o Fax
Fax No. _______________________________________________
o Email
Email address _________________________________________
9.
Check the box that applies to your business activity and provide the date you became or will become required to obtain
a license.
/
/
o Blender
Beginning Date of Business Activity
/
/
o Common Carrier
Beginning Date of Business Activity
/
/
o Exporter
Beginning Date of Business Activity
/
/
o Importer
Beginning Date of Business Activity
/
/
o Local Government User of Diesel Fuel
Beginning Date of Business Activity
/
/
o Mass Transit System Provider
Beginning Date of Business Activity
/
/
o Pollutants
Beginning Date of Business Activity
/
/
o Private Carrier
Beginning Date of Business Activity
/
/
o Retailer of Natural Gas
Beginning Date of Business Activity
/
/
o Terminal Operator
Beginning Date of Business Activity
/
/
o Terminal Supplier
Beginning Date of Business Activity
/
/
o Wholesaler
Beginning Date of Business Activity
10.
A) Do you operate or otherwise control a terminal?
YES o
NO
o
B) If “YES,” state the number of terminals:___________________ and complete the following information for each terminal
location address you operate. If necessary, attach additional sheets.
Terminal Location Address________________________________________________________________________________________
City _______________________________
State ____________ ZIP ______________ Phone No. ________________________
Terminal Location Address________________________________________________________________________________________
City _______________________________
State ____________ ZIP ______________ Phone No. ________________________
Terminal Location Address________________________________________________________________________________________
City _______________________________
State ____________ ZIP ______________ Phone No. ________________________

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