Form Crf-Ifta - Ifta Motor Carrier Registration Application Page 3
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CRF-IFTA (6/13)
GEORGIA DEPARTMENT OF REVENUE
MOTOR VEHICLE DIVISION/IFTA
P.O. BOX 740382
ATLANTA, GA 30374-0382
1-855-406-5221
OWNERSHIP/RELATIONSHIP SECTION
(This section MUST be completed for your application to be accepted)
:
23.
GEORGIA IFTA EFFECTIVE DATE
CHECK ALL THAT APPLY
Owner
Parent Company
Manager
Related Business
Other
Partner
Officer
A
BUSINESS NAME
M.I.
TITLE
SOC SEC NO.*
B
LAST NAME
FIRST
(Required)
C
ADDRESS
D
COUNTY
COU NTR Y
PHONE
CITY
STATE
ZIP
*Please Note: All entities, including businesses, must provide a social security number for owner/operator/partner in Section B or application
will not be processed.
DECLARATION STATEMENT
The applicant agrees to comply with reporting payment, record keeping and license display requirements as specified in
the Georgia IFTA Procedures Manual. The applicant authorizes the State of Georgia to withhold any refund of tax over-
payment, if deliquent taxes are due to any member IFTA jurisdiction. Failure to comply with these provisions shall
grounds for revocation or suspension of the license in all member jurisdictions.
be
The applicant, certifies with his signature that to the best of his/her knowledge, the information is true, accurate and com-
plete and any falsification subjects him/her to the offense of making a written false statement to a government official.
Print Name:
Signature
Title
Date
(Must be signed by owner, partner, or authorized officer of corporation - Stamped signature not acceptable)
Revision Date CRF-IFTA (6/13)
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