Form St-10 - Application For Certificate - South Carolina
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1STATE OF SOUTH CAROLINA
ST-10
DEPARTMENT OF REVENUE
(Rev. 7/98)
5012
APPLICATION FOR CERTIFICATE
Check applicable certificate:
( ) Permanent exemptions(s) at Section 12-36-2120, or
( ) Exclusions at Sections 12-36-120, or
( ) Direct Pay Permit as Section 12-36-2510, or
( ) Exemptions at Section 58-25-80 (Transit Authorities), or
( ) Exemptions at Section 44-96-160 (Motor Carriers), (Code of Laws of South Carolina, 1976, As Amended).
( 1) Name of Business or Firm ________________________________________________________________________
(Please Print or Type)
( 2) Principal or Home Office__________________________________________________________________________
(Street )
(City)
(State)
(ZIP)
( 3) Mailing Address ________________________________________________________________________________
(Street )
(City)
(State)
(ZIP)
( 4) Type of Ownership ________________________________________ ( 4a) Business Telephone (
)
-
A/C
( 5) Owner ______________________________________________________________________________________
(If individual, list full name.)
(If partnership, list all partners. If corporation, list all principal officers.)
( 6) Nature of Business _____________________________________________________________________________
(Mining, Quarrying, Compounding, Processing, Manufacturing, Wholesale, etc.)
(a) If wholesaler, do you make sales to those other than licensed retailers or other wholesalers for resale?
( ) Yes
( ) No
(b) Give a complete explanation of your operations: _____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
(If additional space is required, use reverse side.)
( 7) South Carolina Retail License/Registration No. _______________________ (7a) SSN/FEIN ___________________
(000-00000-0-0000)
( 8) Location of all sales houses,offices or other places of business maintained in South Carolina.
Name under which office or
Retail License or
City
place of business is operated
Address
Registration No.
_________________________________
____________________________________
______________________
______________________
_________________________________
____________________________________ ______________________
______________________
(If additional space is required, use reverse side.)
( 9) Is this application being made for all of your locations? ( ) Yes
( ) No
If No, list below the locations for which
this application is being made.
_________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
(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)
I hereby certify that the foregoing application, including the accompanying schedule, if any, has been examined by me and to the best
of my knowledge and belief, the information contained thereon is true and correct. I understand that if a certificate is issued under one
or more of the foregoing authorities that this certificate is to be CITED ONLY for the items approved thereon by the South Carolina
Department of Revenue.
I understand further that, in the event any of the materials purchased in accordance with the aforementioned 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
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