Form St-10 - Application For Certificate - South Carolina Department Of Revenue printable pdf download

STATE OF SOUTH CAROLINA

1350

DEPARTMENT OF REVENUE

ST-10

APPLICATION FOR CERTIFICATE

(Rev. 7/21/08)

Mail to: SC Department of Revenue, License and Registration,

5012

Columbia, SC 29214-0140

OFFICE USE ONLY

SID

(1) Owner/Partnership/Corporate Name

(If individual, print or type full name.) (If partnership, list all partners. If corporation, list all principal officers.)

(2) SSN/FEI

(3) Name of Business or Firm

(Please Print or Type)

(4) Location Requesting Exemption

(County)

(Street)

(City)

(State)

(ZIP)

(5) Mailing Address

(Street)

(City)

(State)

(ZIP)

(6) Type of Ownership

( 6a) Business Telephone (

)

(Privately owned, partnership, corporation, etc.)

(7) Nature of Business

(Manufacturing, Processing, Mining, Quarrying, Wholesaling, Drycleaning, Broadcasting, Motion Picture, etc.)

(a) Give a complete explanation of your operations:

(If additional space is required, attach a separate page.)

(b) If wholesaler, do you make sales to those other than licensed retailers or other wholesalers for resale?

( ) Yes

( ) No

(8) South Carolina Retail License/Registration No. ______________________ for this location.

(000-00000-0)

(9) List location of all sales houses, offices or other places of business maintained in South Carolina for which this

application applies:

Name under which office or

Retail License or

City

place of business is operated

Address

Registration No.

(If additional space is required, attach a separate page.)

(10) Indicate in space below the exemption number or numbers for which application is made. (See reverse side of this

form for Schedule of Exemptions/Exclusions.)

(11) Location of Records:

(Street)

(City)

(State)

(ZIP)

(12) Contact Person:

Telephone Number:

I hereby certify that this application, including the accompanying schedule, if any, has been examined by me and to the best of my

knowledge and belief, this information is true and correct. I understand that if a certificate is issued under one or more of the listed

authorities that this certificate is to be CITED ONLY for the items approved by the South Carolina Department of Revenue.

I understand further that, in the event any of the materials purchased in accordance with the certificate are withdrawn or used for other

purposes, I will report same to the South Carolina Department of Revenue and remit any tax due thereon.

IMPORTANT

Signature

APPLICATION MUST BE SIGNED BY OWNER, PARTNER

OR IF CORPORATION, AUTHORIZED PERSON.

Title

Date

50121029

Form St-10 - Application For Certificate - South Carolina Department Of Revenue

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