Information Request- Owner Verification

Upon entering the company owner verification information, a confirmation e-mail will be sent regarding your Reseller's Permit / State Sales Tax Certificate Number confirmation.

Company Infomration

Company Name*

Phone*

Company Contact Person*

First Last

Company Ownership

Company Owner / Officer Name*

First Last

Company Owner / Officer - Social Security Number*

Company Owner / Officer - Address*

Street Address City ZIP Code

Authorized Partner / Owner / Officer - Date of Birth*

Signature Confirmation*

I am the named above, an authorized agent or officer, for the company listed above, and I am confirming the order.

Signature of Authorized Person / Officer*

Electronically signing this form will confirm your order. An e-mail confirmation will be sent upon submission of the form.