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.

Purchaser'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 ___________________________________________________