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
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City
State	Zip Code
Phone
Fax

Creditor#2
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City
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Phone
Fax

Creditor#3
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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 05/31/2002 03:31:37 PM