Request for Local Resale Exemption Certificate

My signature below acknowledges I am authorized by the above listed business. I do hereby certify that the information contained herein is true and correct to the best of my knowledge and that the certificate requested will be solely for the purpose(s) specified in this application. Use of this certificate for any purpose other than made known in this application shall subject applicant to full penalties under the law of this state and local ordinances.

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