Purchaser:____________________________________________________________________

Street Address:_________________________________________________________________

City, State, Zip Code:____________________________________________________________

      I hereby certify: That I hold valid Seller’s Permit No. ___________________________issued pursuant to the Sales and Use Tax Law; that I am engaged in the business of selling __________________________________________________________; that the tangible personal property described herein I shall purchase from: _____________________________________________________ will be resold by me in the form of tangible personal property; provided, however, that in the event any of such property is used for any purpose other than retention, demonstration, or display while holding it for sale in the regular course of business, it is understood that I am required by Sales and Use Tax Law to report and pay tax, measured by the purchase price of such property. Description of property to be purchased: _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Date:__________ 20____    

______________________________________________________________________________

Phone(      ) ___________

______________________________________________________________________________

(Signature of Purchaser or Authorized Agent)