(NOTE:  Please print out this page, fill it out, and fax back to us.  Your information will not line up with the blanks if you try to complete it while online.  thanks!)

The undersigned hereby claims exemption to purchases of tangible personal property from NEW LEAF PATTERN DISTRIBUTORS 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 indicated below.

This certificate shall remain in force until revoked and shall be considered a part of each order given to the above vendor unless the order specifies otherwise.

(Purchaser's Name) ______________________________________

(Purchaser's Activity)______________________________________

(Name of Business or Company) ______________________________________

(Purchaser's Telephone No - Business)______________________________________ 

(Purchaser's Address) ______________________________________

(State Sales Tax Number) _________________________________ 

Statutory Reason for Claiming Exemption: (Check One)
_____ For Resale _____Federal, State or Local Government
_____ Church _____Nonprofit Educational Institution
_____ Nonprofit Health Care Organization _____Nonprofit Charitable Organization
_____ Other Nonprofit Exempt Organization _____Other Statutory Reason for Claiming Exemption __________________________________