Arizona MVD Power of Attorney Form

96-0441 R08/06 www.azdot.gov
Company Name Doing Business As (DBA)
Physical Address City State
Zip
Business Phone
( )
Account Number Federal EIN
The following agent is authorized to provide and receive information, and to perform any and all acts that I can
perform as a registrant/taxpayer with respect to International Registration Plan and International Fuel Tax Account
matters.
Authorized Agent Name Phone
( )
Fax
( )
Mailing Address City State Zip
This power of attorney authorizes the above named agent, for the calendar year _______, to:
1. Sign and file all registration, special fuel and motor fuel documents
2. Provide, receive and discuss information regarding the account indicated above
3. Be the Motor Vehicle Division (MVD) point of contact on my behalf
I hereby certify that MVD is authorized to release to the above named agent any and all information in its files with
respect to any matters regarding this account. I relieve MVD and its representatives of any liability related to the
release of such information to the above named agent. I understand that this authorization does not absolve me, as
registrant/taxpayer, of the responsibility to ensure that all tax returns, taxes, license applications and registration
payments are filed and paid on time. Also, I understand that this authorization replaces any prior authorization filed
with MVD.
Authorized Registrant/Taxpayer Name Title
Authorized Registrant/Taxpayer Signature
Acknowledged before me this date.
Notary or MVD Agent Signature
Date County State Commission Expires
POWER OF ATTORNEY
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Arizona MVD Power of Attorney Form PDF

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