Name Title * Telephone *What is the best time to contact you? Do you issue purchase orders? Yes No Are job names required? Yes No do you pay sales tax? Yes No
Trade Reference 1 Phone Number Fax Number Street Address, City, State, Zip Trade Reference 2 Phone Number Fax Number Street Address, City, State, Zip Trade Reference 3 Phone Number Fax Number Street Address, City, State, Zip
* Business Name * Street Address, City, State, Zip Mailing Address, City, State, Zip * Telephone Fax Number * Email * Type of Business * Date Established Employer Identification Number Taxpayer Identification Number is: EIN SSN Reseller's Permit Number Business Operates As: Corporation Partnership Sole Proprietor Business Operates From: Residence Other Business Property Leased: Yes No
I certify that I hold a valid reseller's permit issued pursuant to the Sales and Use Tax Law.
I certify that the product which I shall purchase from Biochem RX, LLC will be resold by me in the form of tangible personal property; provided, however, that in the event any 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 is 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.
I certify that I am not subject to backup withholding because a) I am exempt from backup withholding, or b) I have been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or c) the IRS has notified me that I am no longer subject to backup withholding.
