| Company Name:_______________________________________________________________ |
| Street Address:_________________________________________________________________ |
| City:________________________________State:_______ Zip:___________ |
| Telephone:(_____)______________FAX:(_____)___________ |
| Email:__________________________________________Website:____________________________ |
| How long in Present Business:_______________________ |
| Type of Business: (check one) Proprietorship[_] Partnership[_] Corporation[_] Sub-S Corp [_] LLC[_] |
| Purchases are: Taxable[_] Resale[_] (Please provide a resale certificate for City
and State) |
|
Signature
of Corporate Officer or Owner:________________________________
Title:____________________
Date:____________
Signer's
Printed Name:_______________________________
|
