_________________________________________________
Company Name

_________________________________________________
City, State, Zip

Is exempt from Sales and Use Tax by reason of the following:
_____ Purchases are for resale
_____ Purchases are for industrial processing
_____ Exempt charitable, religious or educational institution
_____ Interstate sale
_____ Some purchases are taxable, purchaser will advise tax status by confirming Purchase Order
_____ Other ______________________________________________________________________

I further certify that if any property purchased tax free is used or consumed by us as to make it subject to a sales or use tax, we will pay the tax due directly to the proper taxing authority when state law so provides.

Sales Tax Number ______________________________________________________________

Applicable State ________________________________________________________________

Authorized Signature __________________________________________________________

Title __________________________________________________________