Gas-1274 Registration Application for

Part 1. Identifying InformationPage of Ownership:ProprietorshipCorporationFiduc iaryPartnershipLLPLLCO ther(Identify) Name (DBA Name) If a corporation or LLC, State of IncorporationSecretary of State NumberDate Attach copy of Articles of Incorporation, LLC or LLP Operating Agreement, Charter, and Certificate of Authority To Do Location(Not Box Number)StreetCityZip CodeCountyStateTelephone NumberFax Address Street or BoxCityZip CodeState7. Email ContactNameTelephone NumberFax of Records (if different from the business location)StreetCityZip CodeStateEmail AddressStreet or BoxCityZip CodeState11. Reporting Service/Tax Preparer Mailing Address NameStreet or BoxCityZip Name and Mailing AddressNameStreet or BoxCityZip CodeStateLessee Name and Mailing Address NameEmail AddressEmail AddressComplete the following if vehicles are involved in a lease agreement.

Gas-1274 Web-Fill 6-20 (Fill in applicable circle for title) 8. Full Name (First, Middle, Last) ... DI = Diesel GA = Gasoline GH = Gasohol LP = Propane LN = Liquid Natural Gas CN = Compressed Natural Gas EL = Electricity ... CT Connecticut DE Delaware GA Georgia FL Florida If yes, list the plate number Yes No IL Illinois IN Indiana

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  Connecticut, Natural, Natural gas

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