Your Company Name: __________________________________________________

I HERE BY CERTIFY, that I hold valid seller's permit No.______________

issued pursuant to the Sales and Use Tax Law that I am engaged in the business of selling______________________ that the tangible personal property described herein which I shall purchase from Carb Lite Solutions will be resold by me in the form of tangible personal property provided, however, that in the event any of such property is used for any purpose other than retention, demonstration or display while holding it for sale in the regular course of business. It is understood that I am required by the Sales and Use Tax Law to report and pay for the tax measured by the purchase price of such property.

Description of property to be purchased_______________________

Date:______________ Print Your Name:________________

Phone:_______________ Signature:_______________________

Please attach a copy of Reseller's Permit and fax to:
ATTN: Business-to-Business Division

Fax (801) 672-3067
Please be sure to write your Sales Order number on form.