Date: Current Business: New Business/Opening:

Name of Store:

Street Address:

City: State: Zip Code:

Name(s) of Owner/Buyer:

Phone: Fax:

Type of Business:  Store:   Catalog: Internet:   Other:

Home address:

City: State: Zip Code:

Phone: Fax:

Email: Web-site

Special Instructions:

A COPY OF YOUR RESALE TAX CERTIFICATE MUST BE FAXED TO 903-962-6471 UNLESS WE ALREADY HAVE IT ON RECORD.