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PCA Customer No.
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Address Cont.:
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Check all that apply to your company
Engaged as a reseller and / or
Use the product in medical procedure(s)

Please enter your resale number for each of the states in which PCA would deliver purchases to your company, and any such purchases would be resold or used in a medical procedure.
State Resale # State Resale # State Resale # State Resale #
AL IL MT RI
AK IN NE SC
AZ IA NV SD
AR KS NH TN
CA KY NJ TX
CO LA NM UT
CT ME NY VT
DE MD NC VA
DC MA ND WA
FL MI OH WV
GA MN OK WI
HI MS OR WY
ID MO PA    
UNIFORM SALES AND USE TAX CERTIFICATION-MULTIJURISDICTION
You further certify that if any property so purchased tax free is used or consumed by the company as to make it subject to a sales or use tax, you will pay the tax due directly to the proper taxing authority. You also agree to fax or e-mail a copy of your license to Peter Storts at 480-383-6249 or e-mail pstorts@pcaskin.com.
 
 I agree

Authorized Signer Name
Title
Date