1.  Purchaser holds a valid Permit,  No________________________________________  issued under the Limited Sales Excise and Use Tax Act of the State  of_______________, which permit has not been revoked or suspended.

2.  That the tangible personal property purchased on each unshipped order heretofore given you and on each order that we shall hereafter give you, UNLESS SUCH ORDER OTHERWISE SPECIFIED, and until this notice and certification is revoked by us in writing is purchased for:   (      )RESALE.     (       )OTHER GROUND of  EXEMPTION:

3.   The general character of the tangible personal property sold, leased or rented by purchaser in the regular course of business is:   (please describe)             
       ________________________________________________________________________________________________
       ________________________________________________________________________________________________

4.   The undersigned purchaser further certifies that he will assume liability for the payment of any tax that may be due under the above described ACT if this transaction is not exempt from such tax.

Dated_______________ 20__________Phone: __________________________________

Purchaser ________________________________________________________________

Address _________________________________________________________________

City ___________________________________ State_________ Zip________________

Authorized By _________________________________________Title ______________

Name of Owner ___________________________________________________________