EXEMPTION CERTIFICATE
GASOLINE 

Seller Name: ___________________________
Seller address: ________________________
Seller City, State and Zip: ______________________

I hereby certify that I am ____________________________ of
                                                          (title)
________________________, and that I am authorized to execute this  (State or local government/public school) this certificate, and that:

all gasoline purchased for the period commencing

(Date)__________ and ending (Date)_________, are or will be (period not to exceed 12 calendar quarters) purchased from _________________________________  for the exclusive use
                            (Name of Company)

of ______________________________.                                        

    I understand that the exemption from tax in the case of sales of articles under this exemption certificate to a State or local government is limited to the sale of articles purchased for its exclusive use(see footnote). I understand that the fraudulent use of this certificate for the purpose of securing this exemption will subject me and all parties making such fraudulent use of this certificate to a fine of not more than $10,000, or to imprisonment for not more than 5 years, or both, together with costs of prosecution.

Date:            _____________________
Signature:     _____________________
Address:       _____________________
                    _____________________
EIN #            _____________________