Form Boe-400-Fco - Application For Supplier And/or Ultimate Vendor Fuel Tax License
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2BOE-400-FCO (FRONT) REV. 1 (4-01)
STATE OF CALIFORNIA
APPLICATION FOR SUPPLIER AND/OR ULTIMATE VENDOR
BOARD OF EQUALIZATION
FUEL TAX LICENSE
SECTION I: TYPE OF LICENSE
FOR BOARD USE ONLY
1. PLEASE CHECK TYPE OF ACTIVITY(S) YOU ARE ENGAGING IN:
TAX
OFFICE
NUMBER
Throughputter
Enterer
Ultimate Vendor (Diesel Fuel Only)
Terminal Operator
Refiner
Blender
Position Holder
PLEASE EXPLAIN YOUR BUSINESS OPERATIONS (attach additional sheets if necessary)
2. CHECK TYPES OF FUEL REMOVED, ENTERED, OR SOLD
Gasoline
Diesel
Dyed Diesel
Aviation Gasoline
Other Please explain
SECTION II: OWNERSHIP INFORMATION
1. PLEASE CHECK TYPE OF OWNERSHIP
Sole Owner
General Partnership (provide a copy of your partnership agreement)
Limited Partnership
Husband/Wife Co-Ownership
(provide a copy of your partnership agreement)
Limited Liability Company (LLC)
Corporation
Business Trust
Joint Venture
Other
2. DATE YOU WILL BEGIN ACTIVITIES REQUIRING A LICENSE IN CALIFORNIA (month, day & year)
3. ENTER NAME OF PARTNERSHIP, CORPORATION, LIMITED LIABILITY COMPANY (LLC), ORGANIZATION, OR OTHER ORGANIZATION
4.Check here if you have included a
copy of your partnership agreement
5. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) OR SSN IF NO FEIN
6. CORPORATE OR LLC NUMBER, STATE OF INCORPORATION OR ORGANIZATION AND DATE
Each owner, partner, corporate officer or principal must complete information below.
If needed, please attach additional sheet(s) to provide the information requested in this application.
Publically traded companies are not required to complete this section.
President
Partner
Manager
Member
Owner
Trustee
7. FULL NAME (first, middle, last)
8. RESIDENCE ADDRESS (street, city, state, zip code)
9. SOCIAL SECURITY NUMBER (attach verification)
10. DRIVER LICENSE NUMBER (attach verification)
11. RESIDENCE TELEPHONE NUMBER
12. DAYTIME TELEPHONE NUMBER
(
)
(
)
13. SIGNATURE
Vice President
Co-Partner
Co-Manager
Member
Co-Owner
Trustee
14. FULL NAME (first, middle, last)
15. RESIDENCE ADDRESS (street, city, state, zip code)
16. SOCIAL SECURITY NUMBER (attach verification)
17. DRIVER LICENSE NUMBER (attach verification)
18. RESIDENCE TELEPHONE NUMBER
19. DAYTIME TELEPHONE NUMBER
(
)
(
)
20. SIGNATURE
Secretary
Co-Partner
Co-Manager
Member
Co-Owner
Trustee
21. FULL NAME (first, middle, last)
22. RESIDENCE ADDRESS (street, city, state, zip code)
23. SOCIAL SECURITY NUMBER (attach verification)
24. DRIVER LICENSE NUMBER (attach verification)
25. RESIDENCE TELEPHONE NUMBER
26. DAYTIME TELEPHONE NUMBER
(
)
(
)
27. SIGNATURE
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