ACCOUNT INFORMATION
*Business Name:
*Billing Address 1:
Billing Address 2:
Billing Address 3:
Billing City:
Billing State:
Billing Zip:
*Billing Address is:
Commercial Residential
 
*Shipping Address 1:		   (If shipping address same as billing address, enter "SAME")
Shipping Address 2:
Shipping Address 3:
Shipping City:
Shipping State:
Shipping Zip:
*Shipping Address is:
Commercial Residential
*Telephone:
Fax:
*Email:
*Email (confirm):
*Vendor License Number:
(If not required in your area, enter "NOT REQUIRED")
*Business hours:
*Date Business Opened:
*Contact Name & Title:
Authorized Buyers:
*1.
2.
3.

*Business Form:
Sole Owner
Partnership
Corporation

*Annual Sales:
under $25,000
$25,000-100,000
$100,000-$500,000 		*Location:
Mall/ Shopping Ctr
Residence
Rural
Other: 		*Store Size:
Less than 1500 sq ft
1500-5000 sq ft
over 5000 sq ft
*Type of Business: Craft/Variety/Hobby
Candy Shop/Bakery
Bakery
Manufacturer
Other:

BLANKET CERTIFICATE OF RESALE

Furnished under the State of Sales & Use Tax Acts

*This is to certify that all purchases by the undersigned from CK South are tax exempt and will be purchased for the following purpose:
For sale as a tangible personal property in the same form as received
To be incorporated as a material, ingredient or component of a new product produced for sale by manufacturing, assembling, processing or refining
To be exported for sale, use or consumption outside the continental limits of the United States
To be sold outside sellers state
This certificate shall be considered part of each order we shall hereinafter place and shall be applicable to any property purchased by the undersigned unless otherwise specified, and shall remain in force until revoked in writing.
*PERMIT NUMBER:
*FID NUMBER:

List all Owners, Partners or Principal Officers

*Name:
*Home Address:
*City:
*State: *Zip:
*Home Telephone:
*Cell Phone Number:
   
Name:
Home Address:
City:
State: Zip:
Home Telephone:
Cell Phone Number:
   
Name:
Home Address:
City:
State: Zip:
Home Telephone:
Cell Phone Number:
   
Name:
Home Address:
City:
State: Zip:
Home Telephone:
Cell Phone Number:
   

By submitting this form, I certify that this information is true and correct to the best my knowledge.

*NAME & TITLE OF PERSON COMPLETING FORM: