Form Dr-156 - Florida Fuel Or Pollutants Tax Application Page 5

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DR-156
R. 01/18
Page 2
11.
Address where business records are maintained (cannot be a post office box) _______________________________________
_______________________________________________________________________________________________________________
City ____________________________
County _______________________________
State ____________
ZIP ___________
Country _____________________________________________
Foreign Postal Code _____________________________________
12.
Mailing address (cannot be a post office box) ______________________________________________________________________
City ____________________________
County _______________________________
State ____________
ZIP ___________
Country _____________________________________________
Foreign Postal Code _____________________________________
13.
Corporation Information
A) License Applicant: Date of Incorporation ______________________________________________________________________
If filing as a corporation, list the state in which you are incorporated: ________________________________________________
List other states where your corporation has operated or is operating: _______________________________________________
–
B) Parent Corporation (if applicable) Parent Corporation FEIN
Parent Corporation Name ______________________________________________________________________________________
Parent Corporation Address ____________________________________________________________________________________
City _________________________
County _______________________________
State ____________
ZIP ___________
Country ________________
Foreign Postal Code ________________
Phone No. ___________________ Ext. ________
NOTE: If incorporated in a state other than Florida, you must attach a certified copy of the certificate or license
issued by the Florida Secretary of State authorizing the corporation to transact business in Florida.
14.
Personnel/Partner Information: Full name, social security number (SSN)*, FEIN (if applicable), and address of each corporate
officer, owner, general partner, stockholder with a controlling interest, and/or director. (Make copies of this page if additional
space is needed.)
–
–
SSN
A) Name ______________________________________________________
(Individual)
–
FEIN
Home Address ______________________________________________
(Business)
City _________________________
County _______________________________
State ____________
ZIP ___________
Country ________________
Foreign Postal Code ________________
Phone No. ___________________ Ext. ________
Corporate or Business Title _______________________________________________________ Interest/Ownership __________%
–
–
B) Name ______________________________________________________
SSN
(Individual)
–
Home Address ______________________________________________
FEIN
(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)
–
FEIN
Home Address ______________________________________________
(Business)
City _________________________
County _______________________________
State ____________
ZIP ___________
Country ________________
Foreign Postal Code ________________
Phone No. ___________________ Ext. ________
Corporate or Business Title _______________________________________________________ Interest/Ownership __________%
* 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 the Department’s website 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.

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