Form Mct-627 - Cancellation Of License Form

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INDIANA REVENUE FORM
INDIANA DEPARTMENT OF REVENUE
MCT-627
MOTOR CARRIER SERVICES DIVISION
Rev. 01/99
CANCELLATION OF LICENSE FORM
Company Name:
DBA Name:
Address:
City:
State:
Zip Code
Please provide all license numbers to which the above cancellation applies:
1.
TID:
2.
IFTA License Number: IN-
3.
Motor Carrier Fuel Tax Permit Number: IN-
4.
Other:
Signature:
Typed or Printed Name:
Title:
Date Signed:
Telephone Number

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