Dr-156t - Florida Temporary Fuel Tax Application Page 3
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5DR-156T
Florida Temporary
R. 01/16
Fuel Tax Application
Page 1
–
1.
Federal Employer Identification Number (FEIN)
FEIN
2.
Business Name ___________________________________________________________ Phone No. __________________________
3.
Trade Name, D.B.A. or A.K.A. _______________________________________________ Fax No. _____________________________
4.
Contact Person ___________________________________________________________ Phone No. _______________ ext. ______
5.
Type and Legal Organization: (Please check only one)
A)
Corporation (check one): C Corp
S Corp
If corporation, check any of the appropriate boxes that apply:
Publicly Held Corporation
Privately Held Corporation
Wholly Owned Subsidiary of a Publicly Held
Corporation
B)
Partnership (check one):
General
Limited
Joint Venture
C)
Limited Liability Company (check one):
Single Member
Multi-member
D)
Individual/Sole Proprietorship
E)
Business Trust
F)
Governmental Agency
6.
Principal Business Location Address (cannot be a post office box) __________________________________________________
City ____________________________
County _______________________________
State ____________
ZIP ___________
Country _____________________________________________
Foreign Postal Code _____________________________________
7.
How would your company like to receive information on Florida fuel tax? (Please check one)
Mail
(U.S. Postal Service)
Fax
Fax No. _______________________________________________
Email
Email address _________________________________________
8.
Please check each box that applies to your business activity.
Importer
Exporter
Common Carrier
Private Carrier
9.
Address where business records are maintained (cannot be a post office box) _______________________________________
_______________________________________________________________________________________________________________
City ____________________________
County _______________________________
State ____________
ZIP ___________
Country _____________________________________________
Foreign Postal Code _____________________________________
10.
Mailing address (cannot be a post office box) ______________________________________________________________________
City ____________________________
County _______________________________
State ____________
ZIP ___________
Country _____________________________________________
Foreign Postal Code _____________________________________
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