Motor Fuel Tax Section
P O Box 1752
Little Rock, AR 72203
Phone. (501) 682-4815   Fax (501) 682-5599
AMFT-71
Registration
Year
ARKANSAS IFTA APPLICATION
1.
Federal Employee ID Number or Social Security No.
2. AR IRP Acct No.
Exp. Date (mm/yyyy)
3. U.S. DOT No.
4.
Applicant's Legal Name
5. Application Type
6.
Trade/DBA Name (If different than Legal Name)
7. Applicant's Arkansas Phone Number
8.
Applicant's Arkansas Physical Address          Street
City
State
Zip
9.
Mailing Address                    Street or P.O. Box
City
State
Zip
10.
Contact Person's Name
11. Contact's Telephone No.
Email Address
12.
Business Type:
13.
PRINT OR TYPE PARTNERS OR CORPORATE OFFICERS NAME(S), TITLE, AND RESIDENCE ADDRESS
NAME Title PHYSICAL RESIDENCE ADDRESS
14.
List Jurisdictions Where You Have Bulk Storage.
15.
NUMBER OF VEHICLES REQUIRING IFTA DECALS
NO FEE
CERTIFICATION – The applicant agrees to comply with reporting, payment, record keeping, and display requirements as specified in the International Fuel Tax Agreement. The applicant authorizes the State of Arkansas to withhold any refund of 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 and any falsification subjects him or her to appropriate civic and/or criminal sanction of the base jurisdiction. APPLICANT AGREES, UNDER PENALTY OF PERJURY, THAT THE INFORMATION GIVEN ON THE IFTA APPLICATION IS, TO THE BEST OF THEIR KNOWLEDGE, TRUE, ACCURATE, AND COMPLETE.

04/24/2014

Applicant's Signature
Applicant's Title
Date




FOR OFFICE USE ONLY

Decal Registration Numbers:
Beginning
Ending
Date Mailed
AR IFTA
Acct No.