Blanket Certificate of Exemption
Prescribed by the Tax Commissioner Under Rule No. TX-11-03
The undersigned hereby claims exemption to purchases of tangible personal property from
(NAME OF VENDOR)
On and after
(DATE)
and certifies that this claim is based upon the purchaser's proposed use of the items purchased, the activity of the purchaser, or both, as shown hereon:
PURCHASER MUST STATE STATUTORY REASON FOR CLAIMING EXEMPTION OR EXCEPTION
This certificate shall continue in force until revoked and shall be considered a part of each order given to the above named vendor unless the order specifies otherwise.
Purchaser's Name :
Purchaser's Activity, i.e., Manufacturer, Public Utility, Church, etc.:
Purchaser's Street Address:
P.O. Box
City
State
Zip
By - Signature:
Title:
Check this box to approve your typed name in the above signature box as your signature
Date Signed:
Vendor's License, if any: