Company Name (Please Print):___________________________________________
Name and Title of Person purchasing (Please Print): ______________________________________
Address (Please Print):__________________________________________________
Phone:( ____)- _____ -____
Email address: _____________________

I HEREBY CERTIFY: That I hold valid seller’s 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: House of Gems, Inc. (DBA:  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: ________________
(Signature of Purchaser or Authorized Agent)