Form Mv Ifta-1 - Application For License International Fuel Tax Agreement - Alabama Department Of Revenue

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MV: IFTA-1 1/17
A
D
R
DEPARTMENT USE ONLY
LABAMA
EPARTMENT OF
EVENUE
I
F
T
A
Approved
NTERNATIONAL
UEL
AX
GREEMENT
Disapproved
Application For License
Effective Date ________
Initials ______________
Registration Period 1/1/20_____ - 12/31/20_____
LICENSEE INFORMATION
Application Type:
Original
Renewal
Ownership:
Individual
Partnership
Corporation
LLC
Other: ___________________________________
Federal Employer’s Identification Number (FEIN):_________________________________________________________________________
Social Security Number (If individually owned): _______________________ IRP Account No.: _____________ USDOT No.: _____________
Applicant’s Legal Name: _____________________________________________________________________________________________
Trade Name (DBA): ________________________________________________________________________________________________
Business Address (must be in Alabama): ________________________________________________________________________________
City: ___________________________________________________________________ State: __________ Zip: ___________________
Mailing Address: __________________________________________________________________________________________________
City: ___________________________________________________________________ State: __________ Zip: ___________________
Contact Person: ____________________________________________________________________________________________________
Telephone Number: (_______)__________________, Ext.: _____________
Fax Number: (_______)__________________ E-Mail Address: _____________________________________________________________
OWNERSHIP INFORMATION
List the names, titles, and addresses of the corporate officers, partners, or managing members.
Name: __________________________________________________
Title: ___________________________________________________
Home Address: ___________________________________________
Social Security Number: ___________________________________
City: ___________________________________________________
State: ________ Zip: _____________________________________
Name: __________________________________________________
Title: ___________________________________________________
Home Address: ___________________________________________
Social Security Number: ___________________________________
City: ___________________________________________________
State: ________ Zip: _____________________________________
Name: __________________________________________________
Title: ___________________________________________________
Home Address: ___________________________________________
Social Security Number: ___________________________________
City: ___________________________________________________
State: ________ Zip: _____________________________________
REPORTING SERVICE
Please complete this section if someone other than a company employee prepares and signs the quarterly fuel use tax report.
Preparer’s Name: __________________________________________________________________________________________________
Telephone Number: (_________)____________________________
Fax Number: (_________)_________________________________
Mailing Address: ___________________________________________________________________________________________________
City: ___________________________________________________
State: ________ Zip: _____________________________________
E-Mail Address: ___________________________________________________________________________________________________
OPERATIONS INFORMATION
Please indicate the fuel type(s) used by the qualified IFTA vehicle by placing a “X” in the appropriate box.
Diesel
Gasoline
Gasohol
LPG
CNG
Ethanol
M-85
E-85
A-85
LNG
Other: ________________________________________________________________________________________________________
Number of IFTA qualified vehicles in your fleet: ____________
Have you ever been issued an IFTA license from a jurisdiction other than Alabama?
Yes
No
If YES, please list those jurisdictions: ________________________________________________________________________________
Has your IFTA license ever been suspended or revoked?
Yes
No
If YES, please list those jurisdictions: ________________________________________________________________________________
Number of IFTA decals requested: ____________ X $17.00 (per decal set) = $ ________________ (amount due)

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