I HEREBY CERTIFY That I hold valid seller's permit

No: ______________________________________________

issued pursuant to the Sales and Use Tax Law;
that I am engaged in the business of selling:

_______________________________________________________________________

_______________________________________________________________________

That the tangible personal property described herein which I shall
purchase from: Ed & Judy's Antiques & Collectibles

will be resold by me in the form of tangible personal property;
PROVIDED, however, that in the event any of 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.

Description of property to be purchased:

_______________________________________________________________________

_______________________________________________________________________

Signature: ____________________________________________________

By and Title: ___________________________________

Dated: __________________________________________

Address: ________________________________________

City: ___________________________________________

Zip: ____________________________________________

PHONE: __________________________________________