Form Reg-3-Mc-1999 - Motor Carrier Road Tax Application
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1DO NOT USE THIS MOTOR CARRIER APPLICATION TO REQUEST INTERNATIONAL FUEL TAX
AGREEMENT (IFTA) DECALS. REQUEST AND COMPLETE FORM CT-IFTA-2 FOR IFTA DECALS.
APPLICATION
STATE OF CONNECTICUT
If registered, enter Connecticut
MOTOR CARRIER ROAD TAX
DEPARTMENT OF REVENUE SERVICES
1999
Tax Registration Number.
Registration Section
REG-3-MC
(Rev. 10/98)
PO Box 2937 Hartford CT 06104-2937
0 0 0
PLEASE READ THE INSTRUCTIONS
THIS APPLICATION IS TO BE USED BY
Please check if your mailing address
PRINTED ON THE BACK BEFORE COMPLETING THIS FORM
NEW ACCOUNTS OR EXISTING ACCOUNTS
has changed, and indicate new address.
TYPE OR PRINT ALL ENTRIES CLEARLY
TO REGISTER ADDITIONAL VEHICLES
FOR DRS USE ONLY
1. REASON FOR APPLYING
TAX
REC
TR
AD
NEW ACCOUNT
REGISTRATION OF ADDITIONAL VEHICLES
OTHER (EXPLAIN)
2. PRINT OWNER, PARTNER OR CORPORATION NAME
SOCIAL SECURITY NUMBER
00
3. PRINT TRADE NAME OR REGISTERED NAME IF DIFFERENT FROM NAME IN LINE 2
FEDERAL EMPLOYER ID NUMBER
00
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
4. PRINT PHYSICAL LOCATION OF BUSINESS (PO Box is not acceptable)
ZIP plus 4
TELEPHONE NUMBER
1 2 3 4 5
1 2 3 4 5
(
)
1 2 3 4 5
00
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
5. PRINT MAILING ADDRESS OF BUSINESS IF DIFFERENT FROM (4) ABOVE
ZIP plus 4
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
00
1 2 3 4 5
6. PRINT NAME AND HOME ADDRESS OF OWNER, PARTNER OR CORPORATE OFFICER ZIP plus 4
SOCIAL SECURITY NUMBER
00
7. PRINT NAME AND HOME ADDRESS OF OWNER, PARTNER OR CORPORATE OFFICER ZIP plus 4
SOCIAL SECURITY NUMBER
00
8. TYPE OF OWNERSHIP (IF “Other,” ATTACH EXPLANATION)
Other
8A. ORGANIZED UNDER LAWS OF WHAT STATE?
Individual
Partnership
Corporation
Limited Liability Company
9. ARE YOU CURRENTLY REGISTERED WITH THE CONNECTICUT DEPARTMENT OF REVENUE SERVICES?
YES
NO
GENERAL
INFORMATION
If “yes,” enter your Connecticut Tax Registration Number in the space provided in the upper right corner of this form.
10. YOU ARE APPLYING FOR IDENTIFICATION MARKERS FOR THE CALENDAR YEAR
1999
YOUR DECALS EXPIRE DECEMBER 31st OF EACH YEAR.
NAME
ADDRESS
ZIP
11. ENTER LESSORS WHO
LEASE VEHICLES TO YOU
NAME
ADDRESS
ZIP
(ATTACH LIST IF NEEDED)
NUMBER OF
12. ENTER EXTENT OF OPERATIONS (See instruction #3 on reverse)
FEES:
QUALIFIED
FEE
AMOUNT DUE
CONNECTICUT ONLY
CONNECTICUT AND ELSEWHERE
THIS SECTION MUST
VEHICLES
BE COMPLETED BY
13. ENTER TOTAL NUMBER OF DECAL SETS REQUESTED
X $10 =
ALL APPLICANTS
Make check or money order payable to: COMMISSIONER OF REVENUE SERVICES
I declare under the penalties of false statement that I have examined this application and to the best of my knowledge and belief it is true,
complete and correct.
DECLARATION
X
AUTHORIZED SIGNATURE
TITLE
DATE
TAX
REC
TRANS
REGISTRATION DATE
SIC CODE
TYPE ORG
STATE
LEGAL DATE
00
10
/
/
/
/
1 2 3 4 5 6 7 8 9 0 1 2
FOR
1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2
TAX
REC
TRANS
REGISTRATION DATE
START DATE
TOWN
SOURCE
FILE CODE
EXT OPR
DRS
1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2
USE
40
/
/
/
/
1
1 2 3 4 5 6 7 8 9 0 1 2
ONLY
SECURITY NO.
SECURITY DATE
SECURITY AMOUNT
REF. BOND DATE
REF. BOND AMOUNT
REG. YEAR
FEE REMITTED
99
/
/
/
/
— DECALS ARE NOT TRANSFERABLE FROM VEHICLE TO VEHICLE OR FROM COMPANY TO COMPANY —
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