Application For Exemption Certificate - Lake Charles, La
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1Sales and Use Tax Department
th
PO Drawer 2050; 2439 6
Street Lake Charles, LA 70602-2050
(337) 217-4280
Fax (337) 217-4281
APPLICATION FOR EXEMPTION CERTIFICATE
Under R.S. 47:305 (D)(4)(b)
Account # ___________
Business Name: ________________________________ Telephone # __________
Business Owner's Name:___________________ Owner's S. S. #_______________
Physical Address:_________________________________________ Zip: _______
Mailing Address:_______________________________________Zip:_______
Name of Physician’s Office: ___________________________________________
Purpose:
The procurement of prescription chemotherapy drugs that will be administered to
patients in a physician’s office where they are not kept as bed patients for 24 hours or more
who have been diagnosed and are being treated for cancer all in accordance with the above
referenced statute.
ACKNOWLEDGEMENT
I, _____________________________________________, acting in an authorized capacity for
the above cited company, do hereby certify that the information contained herein is true and
correct to the best of my knowledge and that the certificate requested will be used solely for the
purpose(s) specified in this application. Use of the certificate for any purpose other than made
known in this application shall subject applicant to full penalties under the law of this state and
local ordinances.
Signed: ________________________________
Date: __________________________________
FOR OFFICE USE ONLY:
Received:_______________________________
Request: ______Granted
______Denied
Expiration Date:________________
If denied, give reason:___________________________________________________________
Signed: ______________________________________
Sales and Use Tax Department
REPRESENTING
Calcasieu Parish School Board, STX Districts 2 & 3, Calcasieu Parish Police Jury, STX Districts 1 & 4A
Calcasieu Parish Law Enforcement District, City of DeQuincy, Town of Iowa, City of Lake Charles
City of Sulphur, Town of Vinton, City of Westlake, SWLa Convention & Visitors Bureau
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