Fillable Printable Tc-760 - Utah State Tax Commission

Tc-760 - Utah State Tax Commission

Representative

First name Middle name Last name Alias/maiden name

Home address (physical address, not P.O. box) City State ZIP Code

Home telephone number Work telephone number Citizenship Date of birth Social Security Number

Gender Height Weight Race Eye color Hair color

Male

Female

ft. in.

Place of birth Driver’s license number State of issue

If you are not a U.S. citizen, you must apply in person at MVED, 210 N 1950 W, Salt Lake City, Utah. Bring proof that you are in the United

States lawfully under 8 U.S.C. 1641. Also bring your employment authorization card and documentation showing the I-94

(arrival/departure) number and Alien Registration Number issued by the U.S. Citizenship and Immigration Service

Under state and federal law we cannot issue a license to any person who does not provide the following residency information:

Check one (Providing false information subjects the signer to the penalties of perjury.):

I am a U.S. citizen. SSN:

________________

I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully. I-94#:

________________

Alien #:

________________

Employment authorization card #:

________________

The Alien Registration Number (A#), I-94 (arrival/departure) number and employment authorization card are issued by the U.S. Citizenship

and Immigration Service.

I hereby apply for a new/renewal Representative License for the year July 1,

_____

through June 30,

______

I certify under penalty of perjury that the statements made on this application are true and correct.

__________________________________ ___________________

Signature of applicant Date

Employer

Business name License number

Business owner’s name (PRINT) Position

I/we certify under penalty of perjury that statements made on this application are true and correct to the best of my/our knowledge and

belief. I/we recommend the applicant to be licensed as a representative of the State of Utah.

__________________________________ ___________________

Signature of owner* Date

*The signer must be an owner, partner or corporate officer, or have power of attorney. Submit a copy of POA, if applicable.

Make check or money order payable to: Utah State Tax Commission

Motor Vehicle Enforcement Division

210 N 1950 W

Salt Lake City, UT 84134



FEE: $26

Utah State Tax Commission

Application for Representative License / New Application

TC-760

Rev. 2/14

Representative number

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