adapters, pipe, flare, sae o-ring, metric, live working swivels, steel hose fittings, brass bards, KR Johnson

 

Online Credit Application

Company Name and Address:
Name: 
Street: 
    City:
   State:   Zip Code:
Phone Number

Fax # 

Dunn & Bradstreet#
Years Business Established: 
Officer/Owner:
Billing Address, If Different:
Name:
Street:
   City:
 State:   Zip Code:
Phone Number

Fax #

Corp.  Partnership   Sole Prop.

Est. Hydraulic Usage $
Title:

References

Bank
Address
City
State Zip Code
Phone
Fax
 
Creditor#2
Address
City
State Zip Code
Phone
Fax
   
Creditor#3
Address
City
State Zip Code
Phone
Fax
 
Creditor#4
Address
City
State Zip Code
Phone
Fax
   

KANSAS DEPARTMENT OF REVENUE

DIVISION OF TAXATION

SALES TAX EXEMPTION CERTIFICATE

  MULTI JURISDICTION

Wholesaler  Retailer  Manufacturer  Lessor  Other

I certify that the firm (buyer) is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product to be resold, leased, or rented in the normal course of our business.  I am in the business of wholesaling, retailing, manufacturing, leasing (renting) the following:
City or State State Registration or ID No. City or State State Registration or ID No.
I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use tax, I will pay the tax due direct to the proper taxing authority when state law so provides or informs the seller for added tax billing.  This certificate shall be part of each order which I may hereafter give to you, unless otherwise specified, and shall be valid until canceled by me in writing or revoked from the city or state.
Description of products to be purchased:
 
CAUTION:  In order for the certificate to be accepted in good faith by the seller, the seller must exercise care that the property being sold is of a type normally sold wholesale, resold, leased, rented, or utilized as an ingredient or component part of a product manufactured by the buyer in the usual course of his business.  A seller failing to exercise due care could be held liable for the sales tax due in some cities or states.  Misuse of this certificate by the seller, lessor, buyer, lessee, or the representative may be punishable by fine, imprisonment, or loss of right to issue certificates in some states or cities 
Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.

Agree   Disagree 

Name of Authorized Party Completing Application:

Last Updated 10/29/2010 11:20:34 AM