Business type and reason for exemption:

Retail Wholesale Non-profit Other, Explain Below

If you selected "other" in the field above please explain here:

Street address:

Street address 2:

City:

State:

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Zip code:

Business phone:

Email address:

State of issue for resale number:

State sales and use number:

State of issue:

Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

I OF CERTIFY THAT ANY AND ALL MERCHANDISE PURCHASED FROM B & M WHOLESALE, INC. IS FOR RESALE OR OTHER EXEMPT USES DEFINED BY THE STATE OF ISSUE AND THIS EXEMPTION WILL REMAIN IN FORCE ON ALL PURCHASES UNTIL CANCELLED BY B & M WHOLESALE IN WRITING OR BY STATE OF ISSUE. UNDER PENALTY OF PURGURY I CONFIRM AND SWEAR THE INFORMATION I HAVE GIVEN IS TRUE AND CORRECT.

ELECTRONIC SIGNITURE:

BUSINESS NAME:

DATE:

YOUR TITLE/POSITION IN COMPANY: