Fillable LICENSING APPLICATION

Fill Online, Printable, Fillable, Blank LICENSING APPLICATION Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LICENSING APPLICATION

On average this form takes 29 minutes to complete

The LICENSING APPLICATION form is 3 pages long and contains:

  • 0 signatures
  • 27 check-boxes
  • 105 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
RDT 120 (07/01/2011)
Regular Mail
UPS air FedEx Priority FedEx StandardUPS ground
CARRIER EXPRESS ACCOUNT NUMBER
Express Mail (fill in account information below)
DMV to send credentials by
OPTION 3 - Fax or mail application - pick up credentials at a DMV Customer Service Center (CSC) in 2 business days.
Carrier pick up credentials at
CUSTOMER SERVICE CENTER NAME
OPTION 4 - Drop off application at DMV Customer Service Center (CSC) - pick up credentials at a CSC in 3 business days.
Carrier pick up credentials at
CUSTOMER SERVICE CENTER NAME
For faster service, use webCAT - DMV's free, on-line, full-service option. webCAT gives you quick, same day service. Go to
www.dmvNOW.com, Commercial services, or contact webcat@dmv.virginia.gov.
INTERNATIONAL FUEL TAX AGREEMENT (IFTA)
LICENSING APPLICATION
(Operations must be in Virginia and at least one other jurisdiction)
CSR NAME
DMV/CSC
Use Only
TO: DMV Motor Carrier Processing Center FAX: 804-367-1073
MAILING ADDRESS: P.O. Box 27412, Richmond, Virginia 23269-0001
CSC LOCATION CODE
FAX/MAILING INFORMATION
Motor Carrier
CARRIER NAME
CSC NAME
Purpose: Use this form to establish a new Virginia IFTA account, or to renew or make changes to an existing Virginia IFTA
account.
Instructions: Submit the completed application to DMV using one of the service options listed below. Any application that can
not be processed will be returned after two weeks.
SERVICE OPTIONS
OPTION 1 - Internet
Service times indicated for each option below are based on DMV Motor Carrier Processing Center receiving this application by
3:00 pm. Service times may vary at the end of the month.
DAYTIME TELEPHONE NUMBER
( )
DATE SENT (mm/dd/yyyy)
TOTAL NUMBER OF PAGES
FAX NUMBER
( )
TELEPHONE NUMBER
( )
FAX NUMBER
( )
OPTION 2 - Fax or mail application - credentials mailed next business day.
AMOUNT TO BE CHARGED
CREDIT CARD
NUMBER
DATE CARD
EXPIRES (mm/yy)
DAYTIME TELEPHONE NUMBER
( )
PAYMENT METHODS
Please indicate payment method type:
NAME APPEARING ON CREDIT CARD
I authorize DMV to charge the
credit card account listed above.
CARD HOLDER SIGNATURE
(Attached)
Check ACH Debit Money Order Credit Card
(Authorization Needed) (Attached) (Complete information below)
CONTACT INFORMATION
If you have questions or need help completing this application, contact Motor Carrier Services at:
(804) 249-5130 (voice) (800) 272-9268 (deaf and hearing impaired only) mcsonline@dmv.virginia.gov (email)
$
RDT 120 (07/01/2011)
CONTACT PERSON NAME
IFTA ACCOUNT TYPE - CHECK ONE BELOW AND ENTER VA IFTA ACCOUNT NUMBER
I: INDIVIDUAL (enter account name)
P: PARTNERSHIP (enter all partners' names)
C: CORPORATION NAME
DO YOU HAVE A
VIRGINIA IRP
ACCOUNT?
YES
IF NO, BUT YOUR BUSINESS OPERATES LEASED VEHICLES THAT DISPLAY IRP PLATES, COMPLETE THE FOLLOWING:
LESSOR IRP ACCOUNT NUMBER VEHICLES LEASED FROM (lessor) NO. OF VEHICLES
NO
Have you ever been licensed as an IFTA Carrier?
NO YES
If IFTA licensed, was license revoked or suspended?
NO YES
IF YES, ENTER VIRGINIA IRP ACCOUNT NUMBER →
If yes, enter jurisdiction and account number
OTHER
DOING BUSINESS AS NAME FEIN/SSN DOT NUMBER
CORPORATION STATE
GENERAL MAILING ADDRESS (if different from business location address)
STATE
VA
STATE
BUSINESS LOCATION STREET ADDRESS (NO POST OFFICE BOX)
CITY ZIP
BUSINESS LOCATION TELEPHONE NUMBER
( )
FAX NUMBER
( )
EMAIL ADDRESS
ZIPCITY
TAX RETURN MAILING ADDRESS (if different from business location address)
BUSINESS INFORMATION
DECAL/LICENSE MAILING ADDRESS (if different from business location address)
ADDRESS WHERE RECORDS ARE LOCATED (if different from business location address)
COUNTRY
BUSINESS LOCATION TELEPHONE NUMBER
( )
FAX NUMBER
( )
EMAIL ADDRESS
STATE ZIPCITY
STATE ZIPCITY
STATE ZIPCITY
APPLICANT INFORMATION
Page 2
VIRGINIA IFTA ACCOUNT NUMBER
TRANSACTION INFORMATION
(check applicable box)
NEW ACCOUNT RENEWAL CLOSE ACCOUNT
ORDER DECALS
CHANGE INFORMATION - My IFTA account needs to be changed to show
the data entered below.
BULK FUEL STORAGE INFORMATION
Do you maintain bulk fuel storage for highway use?
If yes, indicate the fuel type and the jurisdiction where the bulk fuel is stored.
YES NO
FUEL TYPE JURISDICTION FUEL TYPE JURISDICTION FUEL TYPE JURISDICTION
DECAL ORDER (2 decals in each set)
TOTAL FEE DUE
(number of sets times $10.00)
TOTAL NUMBER OF SETS REQUESTEDDECAL YEAR REQUESTED
The decal fee is not refundable.
FEE PER SET
IFTA LICENSING APPLICATION
$
$10.00
RDT 120 (07/01/2011)
IFTA LICENSE AGREEMENT - I certify that I am responsible for fulfilling IFTA requirements, including quarterly tax payments, for leased
vehicles that display IFTA decals and licenses obtained through this application.
RULES AND REGULATIONS - I agree to comply with reporting, payment, record keeping, and license display requirements as specified in the
International Fuel Tax Agreement, Virginia Code and the rules and regulations of the Virginia Department of Motor Vehicles.
DELINQUENT TAXES AND LICENSE REVOCATION - I understand that failure to comply with these provisions shall be grounds for
revocation of my IFTA license in Virginia and/or in all member jurisdictions. I further agree that the Department of Motor Vehicles may
withhold any refunds due if I am delinquent on fuel taxes due to any member jurisdiction.
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 or representation on this form is a criminal violation.
CERTIFICATION
OWNER, PARTNER, OR CORPORATE OFFICER NAME (print)
TITLE
OWNER, PARTNER, OR CORPORATE OFFICER SIGNATURE
DATE (mm/dd/yyyy)
TELEPHONE NUMBER
( )
FAX NUMBER
( )
Page 3
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LICENSING APPLICATION

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document