Order number:#____________________________________________________________________
(Purchase Order number)

Name:______________________________________________________________________
(Name of Purchaser)

Address: _________________________________________________________________________
(Address of Purchaser)

I HEREBY CERTIFY: That I hold valid reseller permit No._______________________ issued pursuant to the Sales and Use Tax Law; that I am engaged in the business of selling: ____________________________________________________________________________; that the tangible personal property described herein which I shall purchase from: _____________________________________________________________________________ will be resold by me in the form of tangible personal property; provided, however, that in the event any of such property is used for any purpose other than retention, demonstration, or display while holding it for sale in the regular course of business, it is understood that I am required by the Sales and Use Tax Law to report and pay tax, measured by the purchase price of such property or other authorized amount. Description of property to be purchased: _____________________________________________________________________________ 

Date: _______________ 20____ 

_____________________________________________ 
(Signature of Purchaser or Authorized Agent) 

_____________________________________________ 
(Title) 

Telephone:(________) ________-________(Require)
(Cell phone , Home or Company) 

E-Mail: ________________________________ 

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Please fax back to:

Fax:(562) 404-0181

or mail to:

FashionWholesaler.com
13128 Imperial Hwy.

Santa Fe Springs, CA 90670