Line 1: Enter Legal Name or Sole Proprietorship, Partnership, Cor- poration, or other legal name.
Lines 3, 5, 6, 7 & 11: Enter the actual location of your business by providing the Street Address, City, State/Province, Zip Code and County* (*Indiana businesses only).
Lines 2,4,8,9,10: Enter the appropriate information ONLY if differ- ent than lines 1,3,5,6,7,11.
Line 12: Enter the area code and telephone number of your prin- ciple place of business.
Line 13: Enter your nine (9) digit Federal Identification Number.
Line 14: Enter your Social Security Number if your business does not have a Federal Identification Number.
Line 15: Enter your INTERSTATE US DOT Number (you will have an Interstate US DOT Number if your vehicle(s) operate outside the state of Indiana.)
Line 16: Enter your Indiana IFTA Tax Identification Number (if based in Indiana.)
Line 17: Enter your IFTA Account Number if based outside the state of Indiana.
Line 18: Enter your Base State/Jurisdiction in which you have your IFTA registered.
Line 19: Enter your Indiana US DOT Number (you will have an IN US DOT Number if your vehicle(s) operate in the state of Indiana only).
Line 20: Enter your Indiana Motor Carrier Account Number.
Line 21: Enter an e-mail address to send/receive correspondence to/from the Department.
Line 22: To be entered by NON-INDIANA CARRIERS ONLY. Check the appropriate business type here. If a CORPORATION, com- plete Line 23. All others go to Line 24.
Line 23: Enter the requested information below. This certificate will not be processed without this section completed.
Line 24: Enter the signature of Taxpayer/Authorized Agent.