State of Rhode Island Division of Taxation 
IFTA-APP 
International Fuel Tax Agreement License Application                                         14123488880101

Applicant legal name                                                                                FEIN

Business name (if different from above)                                                             Registration period ending
                                                                                                    1 2 / 3 1 / 2 0 Y  Y
Physical address                                                   City, town or post office                  State ZIP code

Mailing address (include apt., office or unit #, if any)           City, town or post office                  State         ZIP code

USDOT number                                                       International Registration Plan (IRP) registration number

Date you began or will begin IFTA in Rhode Island                 If you previously registered for IFTA with another jurisdiction, enter jurisdiction below
/             /
Contact name for questions regarding IFTA quarterly tax reporting                             Telephone number
                                                                                             (      )                       -
E-mail address

Type of business:       Individual                       Corporation    Partnership            Other (specify) _____________ 

 Ownership Information: 
 Enter the names, titles, social security numbers and residence addresses of principal officers of a corporation or of  
 members, partners, owners, etc.
                                                                  Social security                             City or Town/ 
  Name                                  Title                                                Address
                                                                     number                                   State/ZIP

                                        Decal Order and License Application 

  Number of vehicles....................................................

                     Mail to RI Division of Taxation - One Capitol Hill - Providence, RI 02908

    State of Rhode Island Division of Taxation 
    IFTA-APP 
    International Fuel Tax Agreement License Application                         14123488880102

 Applicant legal name                                                                        FEIN

Indicate type(s) of fuel used - check all that apply:

    Diesel                              CNG                                         Gasohol
    Motor Fuel Gasoline                 A-55                                        LNG
    Ethanol                             E-85                                        Methanol
    Propane (LPG)                       M-85                                        Biodiesel

Indicate with an "X" the jurisdictions in which you are operating and also those in which you maintain bulk fuel storage  
locations. (OP=Operate; BK=Bulk Fuel)
 OP BK                Jurisdiction   OP              BK    Jurisdiction          OP  BK          Jurisdiction
              AL      Alabama                           NE Nebraska                  CANADIAN PROVINCES
              AZ      Arizona                           NV Nevada                       AB     Alberta
              AR Arkansas                               NH New Hampshire                BC British Columbia 
              CA California                             NJ New Jersey                   MB Manitoba
              CO Colorado                               NM New Mexico                   NB New Brunswick
              CT      Connecticut                       NY New York                     NF     New Foundland
              DE Delaware                               NC North Carolina               NW Northwest Territory
              FL      Florida                           ND North Dakota                 NS Nova Scotia
              GA Georgia                                OH Ohio                         ON Ontario
              ID      Idaho                             OK Oklahoma                     PE     Prince Edward Island
              IL      Illinois                          OR Oregon                       QC Quebec
              IN      Indiana                           PA Pennsylvania                 SK     Saskatchewan
              IA      Iowa                              RI Rhode Island                 YU Yukon Territory
              KS      Kansas                            SC South Carolina
              KY      Kentucky                          SD South Dakota
              LA      Louisiana                         TN Tennessee
              ME Maine                                  TX Texas
              MD Maryland                               VA Virginia
              MA Massachusetts                          WA Washington
              MI      Michigan                          WV West Virginia
              MN Minnesota                              WI Wisconsin
              MS Mississippi                            WY Wyoming
              MO Missouri                               UT Utah
              MT Montana                                VT Vermont

CERTIFICATION:  The applicant agrees to comply with reporting, payment, recordkeeping, and display requirements as specified in the International Fuel 
Tax Agreement. The applicant authorizes the State of Rhode Island to withhold any refund of fuel use tax overpayment, if delinquent taxes are due any  
member IFTA jurisdiction.  Failure to comply with these provisions shall be grounds for revocation of the IFTA license in all member jurisdictions.  
 
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, accurate and complete. 
 Authorized signature                Print name                            Title           Date

 Applicant signature                 Print name                             Date           Telephone number

    State of Rhode Island Division of Taxation 
    IFTA-APP 
    International Fuel Tax Agreement License Application 14123488880103

 Applicant legal name                                                                                    FEIN

                                            VEHICLE IDENTIFICATION NUMBERS 
 
                      For each IFTA decal requested, please provide the plate number, state of registration,  
                                            and the vehicle VIN number for each IFTA qualified vehicle.  
 
                                            You will receive a decal for each vehicle listed.
                               Plate Number  State of Registration                                    Vehicle Identification Number (VIN)
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14 

 15

 16

 17

 18

 19

 20

Please attach additional sheet(s) if needed. Taxpayer spreadsheets containing the above requested information will be  accepted  in lieu of this form.