Exemption Certification
Name of purchaser, firm, or agency as shown on permit
*
Phone Number
*
Please enter a valid phone number.
Texas Sales and Use Tax Permit Number (must contain 11 digits)
Out of State / Country Exempt Number (Non-Texas)
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number
Signature
*
Date
*
-
Month
-
Day
Year
Date
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