Form Dor-Mf-001 - Accounting Or Reporting Firm Authorization Form/responsible Party Page 2

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IN WITNESS WHEREOF, the undersigned has caused these present to be executed, for benefit of the principal
named below.
Please check the following licenses that you hold or are applying for:
Tax License(s)
Tax License(s) Numbers if Previously Assigned
_____ In State Supplier
_________________________________________________
_____ Out of State Supplier
_________________________________________________
_____ Importer
_________________________________________________
_____ Exporter
_________________________________________________
_____ Blender
_________________________________________________
_____ Marketer
_________________________________________________
_____ LPG Vendor
_________________________________________________
_____ CNG Vendor
_________________________________________________
_____ LPG User
_________________________________________________
_____ Highway Contractor
_________________________________________________
_____ IFTA Account
_________________________________________________
_____ Prorate Account
_________________________________________________
_____ SSRS/UCR/Exempt
_________________________________________________
Accounting or Reporting Firm By:
Principle and Licensee By:
___________________________________________
____________________________________
Company Name
Company Name
___________________________________________
____________________________________
Signature of Owner/Legal Rep./Title
Signature of Owner/Legal Rep./Title
___________________________________________
____________________________________
Federal ID Number
Federal ID Number
___________________________________________
____________________________________
Address-Mailing
Address-Mailing
___________________________________________
____________________________________
City/State/Zip
City/State/Zip
____________________________________________
____________________________________
Phone Number
Phone Number
*Indicate your preference for mailing address for
IRP billings, licenses, and all other IRP
material:
Reporting Service_____ Licensee_____
State of _____________________________ )
*
Indicate your preference for mailing address for
: ss.
SSRS/UCR/Exempt notifications
County of ___________________________)
Reporting Service_____ Licensee_____
On this __________day of ______________, before the undersigned, a Notary Public for the State of
(month/year)
_______________________________________personally appeared__________________________________
known to be the person whose name is subscribed to the within instrument, and acknowledge to me that __he
executed the same in capacity as shown.
IN WITNESS WHEREOF, I have set my hand and seal this _____________ day of ____________________, this
certificate above written
(month/year)
_________________________________________
Notary Public
My Commission Expires: ___________________

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