Application For Exempt Certificate (S) - 2004
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1KENAI PENINSULA BOROUGH
144 N. BINKLEY, SOLDOTNA, ALASKA 99669-7599
SALES TAX: (907) 714-2175 or (907) 262-4441, ext. 2175
DALE BAGLEY
FAX (907) 262-8623
MAYOR
APPLICATION FOR EXEMPT CERTIFICATE (S)
CERTIFICATE (S) COST $10.00 EACH – LIMIT 4
ORGANIZATION MUST BE REGISTERED IN ORDER TO RECEIVE AN EXEMPT CERTIFICATE.
ORGANIZATION NAME
REGISTRATION #
OFFICERS:
POSITION:
POSITION:
POSITION:
POSITION:
MAILING ADDRESS
CITY
STATE
ZIP
PHONE #
NUMBER OF CERTIFICATE (S) REQUESTED
1
2
3
4
AMOUNT ENCLOSED
$10.00
$20.00
$30.00
$40.00
NAME OF PERSON (S) WHO WILL CARRY CERTIFICATE(S) PLEASE PRINT LEGIBLY
ORIGINAL EXEMPT CERTIFICATE (S) MUST BE PRESENTED TO THE SELLER AT THE TIME OF
PURCHASE IN ORDER TO RECEIVE THE EXEMPTION, NO COPIES.
CERTIFICATE (S) EXPIRE EVERY DECEMBER 31
FOR OFFICE USE ONLY
EXEMPT CODE
AMOUNT PAID $
Revised: May 28, 2004
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