Form St-10 - Application For Certificate - 2016

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STATE OF SOUTH CAROLINA
1350
DEPARTMENT OF REVENUE
ST-10
APPLICATION FOR CERTIFICATE
(Rev. 7/14/16)
Mail to: SC Department of Revenue, Registration Section,
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/FEIN
(3) Name of Business or Firm
(Please Print or Type)
(4) Location Requesting Exemption
(Street)
(City)
(State)
(ZIP)
(County)
(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)
(12a) Telephone Number
(12) Contact Person
(13) Email address
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I understand further that, in the event any of the materials purchased in accordance with the certificate are withdrawn or used for other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

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