Form Tc-760 - Application For Representative License / New Application

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Utah State Tax Commission
TC-760
Application for Representative License / New Application
Rev. 2/14
Representative number
Representative
First name
Middle name
Last name
Alias/maiden name
Home address (physical address, not P.O. box)
City
State
ZIP Code
Home telephone number
Work telephone number
Citizenship
Date of birth
Social Security Number
Gender
Height
Weight
Race
Eye color
Hair color
Male
Female
ft.
in.
Place of birth
Driver’s license number
State of issue
If you are not a U.S. citizen, you must apply in person at MVED, 210 N 1950 W, Salt Lake City, Utah. Bring proof that you are in the United
States lawfully under 8 U.S.C. 1641. Also bring your employment authorization card and documentation showing the I-94
(arrival/departure) number and Alien Registration Number issued by the U.S. Citizenship and Immigration Service
Under state and federal law we cannot issue a license to any person who does not provide the following residency information:
Check one (Providing false information subjects the signer to the penalties of perjury.):
I am a U.S. citizen. SSN: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully.
I-94#: _ __ _ __ __ __ _ __ __ _
Alien #: _ __ _ __ __ __ _ __ __ _
Employment authorization card #: _ __ _ __ __ __ _ __ __ _
The Alien Registration Number (A#), I-94 (arrival/departure) number and employment authorization card are issued by the U.S. Citizenship
and Immigration Service.
_ __ __
__ _ __ _
I hereby apply for a new/renewal Representative License for the year July 1,
through June 30,
.
I certify under penalty of perjury that the statements made on this application are true and correct.
Form must be signed before submitting.
___ __ _ _ __ __ _ _ _ _ _ __ _ _ _ _ _____ ____ __ _
__ __ _ __ __ __ _ __ __ __ _
Signature of applicant
Date
Employer
Business name
License number
Business owner’s name (PRINT)
Position
I/we certify under penalty of perjury that statements made on this application are true and correct to the best of my/our knowledge and
belief. I/we recommend the applicant to be licensed as a representative of the State of Utah.
Form must be signed before submitting.
___ __ _ _ __ __ _ _ _ _ _ __ _ _ _ _ _____ ____ __ _
__ __ _ __ __ __ _ __ __ __ _
Signature of owner*
Date
*The signer must be an owner, partner or corporate officer, or have power of attorney. Submit a copy of POA, if applicable.
FEE: $26
Make check or money order payable to:
Utah State Tax Commission
Motor Vehicle Enforcement Division
210 N 1950 W
Salt Lake City, UT 84134
IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.
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