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Government Agency Name
Department/Division
Agency Address
Contact Person Name
Contact Email
Contact Phone
State Issued Exemption Number (if applicable)
State Issued ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
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Authorized Representative Name
Title/Position
Signature (Type Full Name)
Date
I certify that this purchase is being made on behalf of a government agency and qualifies for sales tax exemption in accordance with applicable state law.
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