Retailer Registration Form

* Required Fields
* Company Name
* Name of Contact
* Street strAddress
* City
* State
* Zip Code
* Phone
* Email
Fax Number
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How did you hear about us?

Please complete the FORM 13 (Sales Permit Form), below. World Class Emporium can not offer you wholesale prices with out a Sales Permit Number. The Sales Permit Number allows you to purchase merchandise tax free for re-sale purposes. Incomplete certificates cannot be accepted.

RESALE OR EXEMPT SALE CERTIFICATE
For Sales Tax Exemption

FORM 13

Name and Mailing strAddress of Purchaser	Name and Mailing strAddress of Seller
Company Name:	Company Name:
	World Class Emporium
Mailing strAddress:	Mailing strAddress:
	26901 West Park Hwy
strCity:	Ashland
strState:	NE
Zip:	68003

Type of Certificate

Single Purchase Blanket Purchase If blanket, this certificate is valid until revoked in writing by the purchaser.

I hereby certify that the purchase(s), by the above purchaser is/are exempt from sales tax for the following reason:

Purchasing for Resale (Complete Section A) Purchasing with Exempt (Complete Section B)

SECTION A - Resale Certificate

I hereby certify that the purchase of Merchandise from the above seller is exempt from sales tax as a purchase for resale, in the normal course of our business, either in the form or condition in which purchased, or as an ingredient or component part of other property to be resold.

I further certify that we are engaged in business as a: Retailer Wholesaler

Sales Tax Permit Number:

SECTION B - Exempt Sale Certificate
Type of Certificate
Non-Profit Religious Organization Educational Institution Other
If other is checked, please explain:
Tax Exempt Number:	In the strState of:

By submitting this form to World Class Emporium, I am declaring that, to the best of my knowledge and belief, the submitted information is correct and complete. I declare that I am authorized to have World Class Emporium refrain from charging any sales tax for merchandise purchased.
* Authorized person, submitting this form:	* Title of Authorized person:

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