K E N A I  P E N I N S U L A  B O R O U G H
                                                          
                         144 N. BINKLEY · SOLDOTNA, ALASKA 99669-7520 · SALES TAX: (907) 714-2175
      17761                                           WEB SITE: http://www.kpb.us

                         APPLICATION FOR EXEMPT CERTIFICATE
     Exempt Certificates are issued Thursday.  Applications received after 12:00 P.M. on Tuesday
      will not be processed until the following week.
     Original application must be submitted.
     ORIGINAL EXEMPT CERTIFICATE MUST BE PRESENTED TO THE SELLER AT THE TIME OF PURCHASE IN ORDER
       TO RECEIVE THE EXEMPTION, NO COPIES.

SECTION 1: Current Organization Information.
This is a            NEW RENEWAL        REISSUE          Application for January 1 through December 31,
 Check this box if the information below is NOT correct.  Please correct where necessary.
Account #:                             Organization Name:
Mailing Address:                                                                                      Phone #:
City:                                                                            State:               Zip:
Organization activity:

SECTION 2: Officer Information
                         Officer's Name                                                          Title
1
2
3
4

SECTION 3: Name of person(s) who will carry Exempt Certificate(s).
                     One letter per box

1

2

3

4

5

EXEMPT CERTIFICATES EXPIRE ANNUALLY ON DECEMBER 31st                                                    SUPPLEMENTAL

I declare subject to the penalties prescribed in Kenai    GE                            FOR OFFICE USE ONLY
Peninsula Borough ordinances that this application has
been examined by me and to the best of my knowledge       Cash                                        ,   ,   .
and belief is a true and complete application.  I am
                                                          CK#
aware this certificate only exempts the organization's                                                ,   ,   .
purchases and those sales that are not subject to         CK#
federal income tax.  I understand that misuse of the                                                  ,   ,   .
Exempt Certificate is unlawful and subject to             E-Check
                                                                                                      ,   ,   .
prosecution and fine.
                                                          Credit Card                                 ,   ,   .
                                                                                 Total Remitted       ,   ,   .

                     AUTHORIZED SIGNATURE REQUIRED                                      Date