Fillable Rdt120 LICENSING APPLICATION (Virginia Department of Motor Vehicles)

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Rdt120 LICENSING APPLICATION (Virginia Department of Motor Vehicles)

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RDT 120 (07/01/2020)
Fax, mail, drop off at Customer Service Center (CSC) or email application.
No option for same day credential delivery.
Please check desired delivery method:
Electronic Delivery
Special Express Mail (check express mail type and complete account information below)
Regular Mail (allow up to two weeks)
UPS GROUND FEDEX PRIORITY OVERNIGHT
FEDEX STANDARD OVERNIGHT
UPS NEXT DAY AIR
CARRIER EXPRESS ACCOUNT NUMBER
FEDEX EXPRESS SAVER FEDEX 2 DAY
FEDEX FIRST OVERNIGHT
Refer to UPS or FEDEX for details on additional associated fees.
For the fastest service, use DMV's free, on-line, full-service option. VirginiaMCS gives you quick, same day processing service. Go
to www.dmvNOW.com, Commercial services, VirginiaMCS to request access.
PAYMENT METHODS
Payment may be made online at VirginiaMCS.com or to the Motor Carrier IFTA/IRP Work Center.
TRANSACTION INFORMATION
Check applicable box:
NEW ACCOUNT CLOSE ACCOUNT REPLACEMENT LICENSE
ADDITIONAL LICENSE AND DECAL
ORDER
RENEWAL
CHANGE INFORMATION - My IFTA
account needs to be changed to show the
data entered below.
REPLACEMENT LICENSE AND
DECAL
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) • iftairp@dmv.virginia.gov (email)
SERVICE OPTIONS
DMV/CSC
Use Only
TO: DMV Motor Carrier Processing Center FAX: 804-367-1073 EMAIL: IFTAIRP@dmv.virginia.gov
MAILING ADDRESS: P.O. Box 27412, Richmond, Virginia 23269-0001
FAX/MAILING INFORMATION
Motor Carrier
CARRIER NAME
DAYTIME TELEPHONE NUMBER
DATE SENT (mm/dd/yyyy)
TOTAL NUMBER OF PAGES
FAX NUMBER
CSC NAME
TELEPHONE NUMBER FAX NUMBER
CSC LOCATION CODE
CSR NAME
Purpose: Use this form to establish a new Virginia IFTA account, to renew or to make changes to an existing Virginia IFTA
account (Operations must be in Virginia and at least one other jurisdiction).
Instructions: Submit the completed application to DMV using one of the service options listed below. After two weeks any
application that can not be processed will be destroyed.
INTERNATIONAL FUEL TAX AGREEMENT (IFTA)
LICENSING APPLICATION
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RDT 120 (07/01/2020) -- Page 2
IFTA LICENSING APPLICATION
CONTACT PERSON NAME CONTACT TELEPHONE NUMBER FAX NUMBER
EMAIL ADDRESS
CONTACT BUSINESS LOCATION ADDRESS
STATE ZIPCITY
The contact is authorized to conduct transactions and receive information pertaining to those transactions on behalf of the carrier/applicant.
AFFILIATION
WITH
COMPANY
COMPANY EMPLOYEE
AGENT
ACCOUNTANT
OTHER:
OWNER
CONTACT INFORMATION
GENERAL MAILING ADDRESS (if different from business location address)
STATE ZIPCITY
TAX RETURN MAILING ADDRESS (if different from business location address)
DECAL/LICENSE MAILING ADDRESS (if different from business location address)
ADDRESS WHERE RECORDS ARE LOCATED (if different from business location address)
STATE ZIPCITY
STATE ZIPCITY
STATE ZIPCITY
STATE
VA
BUSINESS LOCATION STREET ADDRESS (NO POST OFFICE BOX)
CITY ZIP
LOCATION TELEPHONE NUMBER FAX NUMBER
BUSINESS INFORMATION
COUNTRY
IF NO, BUT YOUR BUSINESS OPERATES LEASED VEHICLES THAT DISPLAY IRP PLATES, COMPLETE THE FOLLOWING:
LESSOR IRP ACCOUNT NUMBER(S)VEHICLES LEASED FROM (lessor(s)) NO. OF VEHICLES
Have you ever been
licensed as an IFTA Carrier?
YES
NO
FEIN/SSN DOT NUMBER TOTAL NUMBER OF QUALIFIED VEHICLESVIRGINIA IFTA ACCOUNT NUMBER
IFTA ACCOUNT TYPE - (check one)
ENTER LEGAL BUSINESS NAME (individuals give full legal name)
DOING BUSINESS AS NAME
APPLICANT INFORMATION
Individual Partnership (include all names below) Corporation Limited Liability Company
STATE BUSINESS FORMED IN
Indicate officers of the company and role (use additional sheet(s) if necessary)
OFFICER'S NAME OFFICER'S EMAIL OFFICER'S ROLE IN COMPANY
FLEET IDENTIFIER
IF YES →
ACCOUNT NUMBER JURISDICTION
WAS IFTA LICENSE REVOKED OR
SUSPENDED?
YES
NO
Do you have a Virginia IRP Account? YES NO
IF YES →
VIRGINIA IRP ACCOUNT NUMBER
TOTAL IRP VEHICLES
NON-APPORTIONED VEHICLES
TOTAL NON-APPORTIONED
VEHICLES
IRP is not required for vehicles that display restricted plates.
Indicate the type of restricted plate:
Other:
Indicate the type of fuel(s) purchased and placed into the qualified motor vehicles:
Gasoline Diesel
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RDT 120 (07/01/2020) -- Page 3
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.
I certify that the individual indicated as the contact is authorized to conduct transactions and receive information pertaining to those
transactions on behalf of the carrier/applicant.
CERTIFICATION
OWNER, PARTNER, OR COMPANY OFFICER NAME (print)
TITLE
OWNER, PARTNER, OR COMPANY OFFICER SIGNATURE DATE (mm/dd/yyyy)
TELEPHONE NUMBER FAX NUMBER
BULK FUEL STORAGE INFORMATION
Do you store bulk fuel 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
AUTOMATED SERVICES (OPT IN/OUT)
Check to indicate election
YES
I would like to OPT INTO electronic notifications with Motor Carrier Services.
NOTE: All IFTA correspondences and notifications will be sent by email to the contact specified on page two. It is your responsibility
to keep the email address up to date.
I would like to OPT OUT OF electronic notifications with Motor Carrier Services.
NOTE: All IFTA correspondences and notifications will be sent by mail.
I would like to OPT INTO automated license and decal renewal.
I would like to OPT OUT OF automated license and decal renewal.
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$10.00
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Rdt120 LICENSING APPLICATION (Virginia Department of Motor Vehicles)

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Completed 29 July 2020

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