17050 Evergreen Place
City of Industry, CA 91745
Tel: 877-246-8294 Fax: 626-810-8313
Request for Tax Exempt - CA Reseller
Dear Customer,

Due to California Tax Regulations, verification of a tax exempt permit is required. Please complete the form and fax it to (626)810-8313 as soon as possible. Please also provide a copy of your tax exempt permit. Thank you.

Company Information
Billing Address
Company :__________________________________

Contact Person: _____________________________

Phone #:____________________________________

E-mail: _____________________________________

Address 1: ________________________________

Address 2: ________________________________

City :____________________________________

State:_______ Zip:_________________________

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 it understood that I am required by the Sales and Use Tax Law to report and pay for the tax, measured by the purchase price of such property.

Description of property to be purchased: ______________________________________________________________________________



Signature: X___________________________________________________                                        Date:___________________