FT 510 (04/20/2017)
VIRGINIA FUELS TAX ELECTRONIC/INTERNET FILING
APPLICATION
Purpose: Use this form to apply for the capability to file the Virginia fuels tax activity information electronically using
Conduent Business Services, LLC., the Virginia-approved vendor.
Instructions: Print in ink or type to complete form. Fax completed form to (804)367-0233.
DISCLAIMER
APPLICATION DATE (mm/dd/yyyy)
COMPANY NAME
FEIN
ADDRESS
VIRGINIA FUELS TAX LICENSE NUMBER LICENSE TYPE (list all types of licenses held)
CONTACT PERSON NAME TELEPHONE NUMBER EMAIL ADDRESS
TRANSMISSION FORMAT INFORMATION
APPLICANT INFORMATION
CHECK THE BOX WHICH INDICATES HOW YOU WILL TRANSMIT ELECTROINIC DATA
EDI ANSI X.4030 ASCII FLAT FILE INTERNET (WEB)
CERTIFICATION
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand
that knowingly making a false statement on this form is a criminal violation.
DATE (mm/dd/yyyy)
PERSON AUTHORIZED TO SIGN APPLICATION (print name) SIGNATURE
The Conduent system is for the use of authorized clients only. To protect the computer network system from unauthorized use and to ensure the computer
network system is functioning properly, system administrators monitor this system. Individuals using the computer network system without authorization,
or in excess of their authorization, are subject to having all their activity on this computer network system monitored and recorded by system personnel.
Anyone using this computer network system expressly consents to such monitoring and is advised that if such monitoring reveals possible conduct of
criminal activity, system personnel may provide the evidence of such activity to law enforcement officers. Access is restricted to authorized users only.
Unauthorized access is a violation of state, federal, civil, and criminal laws.
CONDUENT COMPANY USE ONLY
MFT ACCOUNT IDENTIFICATON
