A person may obtain a temporary importer, exporter, pollutant, or carrier fuel tax license when the Governor of Florida has declared a state of emergency, or when the President of the
United States has declared a major disaster in Florida or in any other state or territory of the United States.
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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
Partnership (check one): ¦
General ¦
LimitedB) ¦
Joint Venture
Limited Liability Company (check one):
¦
C) ¦
Single Member ¦
Multi-member
Individual/Sole Proprietorship
Business Trust
Governmental Agency
¦
D) ¦
E) ¦
F) ¦
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. _______________________________________________
¦
E-mail E-mail address_________________________________________
8.
Please check each box that applies to your business activity.
¦
Importer
¦
Exporter
¦
Common Carrier
¦
Private Carrier9.
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 _____________________________________– –
–
– –
–DR-156T
R. 10/09
11.
Corporation Information
Page 2A) License Applicant: Date of Incorporation ______________________________________________________________________
If filing as a corporation, list the state in which you are incorporated: ________________________________________________
List other states where your corporation has operated or is operating:_______________________________________________B) Parent Corporation (if applicable) Parent Corporation FEIN
Parent Corporation Name______________________________________________________________________________________
Parent Corporation Address____________________________________________________________________________________
City _________________________ County _______________________________ State ____________ ZIP ___________
Country ________________ Foreign Postal Code ________________ Phone No.___________________ Ext. ________NOTE: If incorporated in a state other than Florida, you must attach a certified copy of the certificate or license
issued by the Florida Secretary of State authorizing the corporation to transact business in Florida.
12.
Personnel/Partner Information: Full name, social security number (SSN), FEIN (if applicable), and address of each corporate
officer, owner, general partner, stockholder with a controlling interest, and/or director. (Make copies of this page if additional
space is needed.) NOTE: Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the
administration of Florida’s taxes. SSNs obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida
Statutes, and not subject to disclosure as public records. Collection of your SSN is authorized under state and federal law. Visit our Internet
site at www.myflorida.com/dor and select “Privacy Notice” for more information regarding the state and federal law governing the collection,
use, or release of SSNs, including authorized exceptions.A) Name ______________________________________________________ SSN
(Individual)
Home Address ______________________________________________ FEIN
– –
–(Business)
City _________________________ County _______________________________ State ____________ ZIP ___________
Country ________________ Foreign Postal Code ________________ Phone No.___________________ Ext. ________
Corporate or Business Title _______________________________________________________ Interest/Ownership __________%B) Name ______________________________________________________ SSN
(Individual)
Home Address ______________________________________________ FEIN (Business)
City _________________________ County _______________________________ State ____________ ZIP ___________
Country ________________ Foreign Postal Code ________________ Phone No.___________________ Ext. ________
Corporate or Business Title _______________________________________________________ Interest/Ownership __________%C) Name ______________________________________________________ SSN
(Individual)
Home Address ______________________________________________ FEIN (Business)
City _________________________ County _______________________________ State ____________ ZIP ___________
Country ________________ Foreign Postal Code ________________ Phone No.___________________ Ext. ________
Corporate or Business Title _______________________________________________________ Interest/Ownership __________%D) Name ______________________________________________________ SSN
Home Address ______________________________________________ FEIN
City _________________________ County _______________________________ State ____________ ZIP ___________
Country ________________ Foreign Postal Code ________________ Phone No.___________________ Ext. ________
Corporate or Business Title _______________________________________________________ Interest/Ownership __________%–
– – (Individual)
– (Business)DR-156T
R. 10/09
Page 3
13. Carrier Information
A) Do you transport petroleum products/fuels
over the highways and/or waterways of Florida? …………. ¦
YES ……….. ¦
NO
If “YES,” are you a common carrier? ………………………….. ¦
¦
YES ……….. ¦
¦
NO …………………….. If “NO,” go to question 13(B)
If “YES,” what mode of transportation
is used to transport the fuel/petroleum products?
TruckRail
¦
Vessel
¦
Pipeline
B) If you are not a common carrier, list the make/model, year, vehicle identification number, and total tanker capacity of each
truck, barge, boat, or other equipment used to transport fuel on the highways or waterways of Florida. Cab cards will be
issued for each motor vehicle or item of equipment used to transport fuel. (If necessary, attach a separate sheet.)Make/Model Year Vehicle ID Number Tanker Capacity (in Gallons)
14. Pollutants Storage Information
Will this business import pollutants into this state? ………….. ¦
YES ……….. ¦
NO
Licensing Information15. Are you registered to collect and/or remit sales tax? ………………………………………………………………………….
…… ¦
¦
YES
¦
¦
¦
¦
¦
NO16. Will this business import fuels into Florida upon which there has been no precollection of Florida tax?
YESNO
17. Do you transport petroleum products either for yourself or for hire? ……………………………………………………. ¦
YES
NO18. Do you export fuels from this state other than by pipeline or marine vessel? ………………………………………… ¦
YES
NO19. Do you have a fuel license issued by another state? ………………………………………………………………………….. ¦
YES
NO
IF yes, please provide the state and license number. State ________________ License Number_______________________Affidavit of Applicant(s)
I, the undersigned individual(s), or if a corporation for itself, its officers, and directors, hereby swear or affirm under penalty of
perjury as provided in section 837.06, Florida Statutes, that I am duly authorized to make the foregoing application and that the
application and all attachments are true and correct representation(s) of the premises to be licensed. If licensed, I agree that the
place of business may be inspected and searched, during business hours or at any time business is being conducted on the
premises, by officials and agents of the Department of Revenue for the purposes of determining compliance with Chapter 206, F.S.Sworn to (or affirmed) and subscribed before me
State of_____________ County of ________________________________ this ____________ day of ___________________ , ____________ .
Signature of Applicant Signature of Notary Public
Print or Type Applicant’s Name
WARNING:
Print, Type or Stamp Name of NotaryPersonally Known __________ or Produced Identification__________
Read carefully: This instrument is a sworn document. False answers
could result in criminal prosecution subject to fine and/or imprisonment Type of Identification Produced ___________________________________
and denial of your application.