NOTE:   Please fill out the Resale Certificate Form, print and sign the form then mail it

                                with your Credit Application to the address given on the Credit Application Form. 

                                You are welcome to fax a copy of this form to our credit manager, however, the

                                application process will not be completed until we receive the signed, original by mail.          

                                                                                RESALE CERTIFICATE

1.    Name of Seller: 

2.    Name of Buyer/Business: 

3.    Address of Buyer: 

                                            Street                                                              City, State                                                 Zip                                      

4.    Buyer's UBI/Revenue Registration Number: 

5.    Buyer is in the business of: 

6.    Types of items purchased for resale: 

I (the buyer) certify that I am purchasing the items listed on line 6 (please check appropriate box):

        for resale in the regular course of business without intervening use in the regular course of business;

        for use as an ingredient or component part of a new article of tangible personal property to be

               produced for sale, or;

        as a chemical to be used in processing a new article of tangible personal property to be produced for sale, or;

        for use as feed, seed, seedlings, fertilizer, or spray materials in my capacity as a farmer.

I acknowledge that I am solely responsible for purchasing within the categories listed on line 6.  I acknowledge that

misuse of the resale privilege claimed by use of this certificate subjects me to a penalty of 50 percent of the tax due,

in addition to the tax, interest, and any other penalties by law.

Printed Name: _________________________________________________________________________________

                                                                            Name of Person Authorized to Use Resale Certificate

Signature:  ____________________________________________________________________________________                                  

                                                                                                                 Signature of Person Authorized to Use Resale Certificate

Effective Date:  ___________________________________through_______________________________________

                                                                                       (Not to exceed 4 Years)

                                                                                                                                                                                                                                                     YB 10/99

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