Name of Business: *

Tax ID #: *

Phone *

Address: *

City *

State: *

Zip: *

Contact Name: *

Email *

Type of Business:

In Business Since:

Legal Form Under Which Business Operates: *

Corporation
Partnership
Proprietorship

Please specify your business type

If Division/Subsidiary, Name of Parent Company:

In Business Since:

Name

Title:

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Name

Title:

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Purchase Order Required: *

A.P. Contact Name:

A.P. Phone Number:

A.P. Contact Email:

Special Instructions:

Please select one(1) option below:

Invoices will be paid with a credit card
Invoices will be paid by ACH

By signing this form, you authorize Jackman Wheels to collect payment via the method selected above. All invoice amounts payable in U.S. dollars

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Printed Name:

Title: *

Date:

California Resale Certificate

I HEREBY CERTIFY:

I hold valid seller’s permit number: *

I am engaged in the business of selling the following type of tangible personal property: *

This certificate is for the purchase from of the item(s) I have listed in paragraph 5 below. *

I will resell the item(s) listed in paragraph 5, which I am purchasing under this resale certificate in the form of tangible personal property in the regular course of my business operations, and I will do so prior to making any use of the item(s) other than demonstration and display while holding the item(s) for sale in the regular course of my business. I understand that if I use the item(s) purchased under this certificate in any manner other than as just described, I will owe use tax based on each item’s purchase price or as otherwise provided by law.

Description of property to be purchased for resale:

I have read and understand the following:

For Your Information: A person may be guilty of a misdemeanor under Revenue and Taxation Code section 6094.5 if the purchaser knows at the time of purchase that he or she will not resell the purchased item prior to any use (other than retention, demonstration, or display while holding it for resale) and he or she furnishes a resale certificate to avoid payment to the seller of an amount as tax. Additionally, a person misusing a resale certificate for personal gain or to evade the payment of tax is liable, for each purchase, for the tax that would have been due, plus a penalty of 10 percent of the tax or $500, whichever is more.

Please upload your Sellers Permit: *

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Supported format: JPG, JPEG, PDF, PNG, GIF, SVG.

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Please upload your tax ID documents, and documentation of legitimate business.

Name of Purchaser: *

Signature of Purchaser: *

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Printed Name of Person Signing:

Address of Person Signing:

Phone Number:

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We appreciate you registering with us. A sales representative will be in touch shortly.

Have a great day!

Thanks for registering with us!

We appreciate you registering with us. A sales representative will be in touch shortly.

Have a great day!

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