BOC-3 Information Form – MASERVIGESTION CORPORATION

Blank Form (#6)

Basic Information

please complete the following information.

First Name

Last Name

Email Address

Contact Phone

SERVICES

Please select the service you need.

Service Category

EIN & IRS Support

International Fuel Tax Agreement (IFTA)

International Registration Plan (IRP)

Unified Carrier Registration (UCR)

FMCSA & US DOT Filings

EIN & IRS SERVICES

Please select the service you are requesting.

BUSINESS INFORMATION

Legal Business Name

EIN / FEIN

State of Formation

Entity Type

Business Start Date

State ID Number

BUSINESS ADDRESS

Business Address

Address Line 1

City

State

Zip Code

IFTA SERVICES

Please select the service you are requesting.

Type of IFTA Service Needed

New IFTA Registration

IFTA Renewal

Quarterly IFTA Filing

IFTA Account Update / Amendment

IFTA ACCOUNT INFORMATION

Address

Address Line 1

City

State

Zip Code

Do you currently have an IFTA account?

Yes

IFTA Account Number

New Business Name

Number of Vehicles

Fleet Type (New / Existing)

BOI – RESIDENTIAL ADDRESS

Residential Address

Enter the residential (home) address. PO Boxes are not allowed.

City

State

Zip Code

USDOT Number

BOI – IDENTIFICATION INFORMATION

Some description about this section

Date of Birth

Identification Number (Passport or Driver’s License)

Upload Supporting Documents

Choose File

SERVICE-SPECIFIC QUESTIONS

Has any information changed?

Yes

What information changed?

Business Address

Officers / Members

Business Name

Management Structure

New Business Address Line 1

Address Line 1

City

State

Zip Code

Officers / Members

Officer / Member Full Name

Title / Position

Ownership Percentage (%)

Describe the changes made

AUTHORIZED / RESPONSIBLE PERSON

Responsible Party Full Name

Authorized Person Name

Authorized Person Title

Owner

Member

Manager

President

SUPPORTING DOCUMENTS

Choose File

FMCSA / USDOT INFORMATION

Some description about this section

MC Number (opcional)

Base State

Trade Name / DBA (opcional)

Business Phone Number

OWNER / OFFICER INFORMATION

SSN / ITIN ( 999-99-9999)

Officer / Member Full Name

CONTACT & AUTHORIZATION

Authorization Consent

I certify that the information provided is accurate and I authorize MASERVIGESTION CORPORATION to prepare and submit filings on my behalf with IRS, state agencies, and other authorities as required.