Blanket Certificate of Exemption
The undersigned hereby claims exemption to purchases of tangible personal property from
_______________ H.E. Long Company _______________________
(name of vendor)
on and after
_________________________________________ and certifies that this claim is based(date)
upon the purchaser's proposed use of the item purchased, the activity of this purchaser, or both as
shown hereon:
_________________________________________________________________________________
_________________________________________________________________________________
(
purchaser must state statutory reason for claiming exemption or exception)
This certificate shall continue until revoked and shall be considered a part of each order given to the
vendor stated above unless the order specifies otherwise.
P
urchaser's name ___________________________________________________
Purchaser's Activity, ________________________________________
i.e. Manufacturer, Distributor, etc
Purchaser's Street Address ___________________________________________________
City, State Zip ___________________________________________________
Tax I.D. License Number ___________________________________________________
Signature and Date ___________________________________________________