Form E-595ea - Application For Exemption Number For Qualified Purchases - 2011
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14
E-595EA
Application for Exemption Number
Web-Fill
for Qualified Purchases
PRINT
CLEAR
2-11
North Carolina Department of Revenue
Office Use
1.
If Corporation, Partnership, or LLC
If Proprietorship then enter
Federal Employer ID No.:
Social Security Number:
enter
2.
Type of Ownership:
Proprietorship
Corporation
Partnership
LLC
Other (Identify)
3.
Owner’s Legal Name:
4.
Trade Name (DBA Name):
5.
Street Address:
Street
(Not P.O. Box Number)
City
State
Zip Code
County
6.
Mailing Address:
Street or P.O. Box
City
State
Zip Code
7.
Type of Business or Profession:
Farmer
Commercial Fisherman
Commercial Logger
Veterinarian
8.
Dollar amount of annual income from business or professional activities:
Check if just started within the year.
Check if just moved to North Carolina.
9.
Describe the type of items sold and/or produced or services rendered:
Signature:
Date:
I certify that, to the best of my knowledge, this application is accurate and complete.
Name (Print):
Title:
E-mail:
Phone:
Mail to: N.C. Department of Revenue, Exceptions\Registration
P. O. Box 25000, Raleigh, NC 27640-0001
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