Form 74-026-001-01 - Registration Application For International Fuel Tax Agreement (Ifta) Credentials - 2001

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Form 74-026-001-01 Rev 02/2001
MISSISSIPPI
Registration Application for International Fuel
Tax Agreement (IFTA) Credentials
1.
Enter your Federal I. D. Number if a corporation or partnership or Social Security Number if sole owner.
Federal I D No. ___ ___ - ___ ___ ___ ___ ___ ___ ___ Social Security No. ___ ___ ___- ___ ___ - ___ ___ ___ ___
2. Legal Name Of Applicant
Business Name (DBA)
3. Street Address:
City
State
Zip Code
County
4. Contact Person
Telephone Number:
Fax Number:
Internet E-mail Address:
5. Mailing Address:
City
State
Zip Code
County
6. Type of Ownership:
Corporation
Partnership - General
Sole Ownership
S Corporation
Partnership - Limited
Other
LLC
LLP
7. If C Corp., S Corp, LLC, LLP, or Partnership, list the names of the officers or partners.
Name
Address
Title
Social Security No.
8. Corporation organized under Laws of State of
9. Date admitted or authorized to do business in Mississippi
Date began business
10. Have you previously held International Fuel Tax Agreement (IFTA) Credentials?
Yes
No .
If yes, please indicate the Account No.
and the base jurisdiction
11. Complete the following if your vehicles are leased to another motor carrier.
Name and address of lessor
Lessor's Phone
12. Who is responsible for reporting Interstate Motor Carrier Fuel Taxes:
Lessor
Lessee
13. If a Reporting Service completes your fuel tax report, give its Name, Address, and Phone Number.
14. Do you want your Tax Report mailed to the Reporting Service?
Yes
No
15. If a Reporting Service completes your fuel tax report, please execute a Power of Attorney.
APPLICATION
FOR INTERNATIONAL FUEL TAX AGREEMENT (IFTA)

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