Form Dr-176 Draft - Application For Air Carrier Fuel Tax License
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3DR-176
Application for Air Carrier Fuel Tax License
R. 01/18
Rule 12B-5.150
Florida Administrative Code
Effective 01/18
You must complete this application with appropriate attachments and receive approval by the Florida Department of
Revenue before engaging in or conducting business involving fuel in the State of Florida.
–
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.
Type and Legal Organization: (Please check only one)
A)
Corporation (check one):
C Corp
S Corp
If corporation, check all boxes that apply:
q
q
q
Publicly Held Corporation
Privately Held Corporation
Wholly Owned Subsidiary of a Publicly Held
q
q
q
Corporation
B)
Partnership (check one):
General
Limited
Joint Venture
q
q
q
q
C)
Limited Liability Company (check one):
Single Member
Multi-member
q
q
q
D)
Individual/Sole Proprietorship
q
E)
q
Business Trust
F)
Governmental Agency
q
6.
Principal Business Location Address (cannot be a post office box) __________________________________________________
City ____________________________
County _______________________________
State ____________
ZIP ___________
Country _____________________________________________
Foreign Postal Code _____________________________________
7.
Do you receive tax-free aviation fuel under U.S. Customs bond?
q
Yes
q
No
If yes, enter the number of gallons received each month________________________________
8.
Corporation Information
A) License Applicant: If filing as a corporation, list your state of incorporation: _________________________________________
List other states where your corporation has operated or is operating: _______________________________________________
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Parent Corporation FEIN
B) Parent Corporation (if applicable)
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.
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