Name of Company:
Name of Purchaser:
Address of Company:
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 which 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 property or other authorized amount.

Description of property to be purchased:
Date :
Printed Name of Purchaser:
By and Title: