Ets Form 124 A - Non-Resident Contractor Sales And Use Tax Bond Covering A Single Contract - 2001 Page 2

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PRINCIPAL
Signed and executed this ______ day of _______________, 20___.
By:
________________________________________
(Signature)
Corporate Seal
________________________________________
Printed or Typed
TITLE:________________________________________
State of:____________________________ )
)
SS.
County of:__________________________ )
There foregoing performance and payment bond was acknowledged before me by
__________________________this _____day of ______________20 ___.
Witness my hand and official seal.
____________________________________
Notary Public
My commission expires:___________________
SURETY
Signed and executed this _____ day of __________, 20____.
BY:
_______________________________________
Signature
Corporate Seal
_______________________________________
Printed or Typed
TITLE:_______________________________________
State of__________________________________ )
)
ss.
County of________________________________ )
There foregoing performance and payment bond was acknowledged before me
by____________________________ this _____ day of ____________ 20 ___.
Witness my hand and official seal.
______________________________________
Notary Public
My commission expires:
________________________________
Non-Resident Contractor Sales and Use Tax Bond
__________________, Principal, and _________________,Surety
Bond No.________________
Page 2 of 2
ETS Form 124 a (Rev 5/8/01)

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