Cal. Code Regs. Tit. 18, div. 2, ch. 4, art. 18, app A
I certify that I operate an independent business at the premises of the following retailer and that I hold a valid seller's permit to operate at this location, as noted below. I further understand that I will be solely responsible for reporting all sales that I make on those premises and remitting all applicable sales and use taxes due to the California Department of Tax and Fee Administration:
___________________________
Name of retailer on whose premises I operate my business:
___________________________
Location of premises:
___________________________
I hereby certify that the foregoing information is accurate and true to the best of my knowledge:
| Certifier's Signature: ______________________________________________________ | Date: _____________ |
| Certifier's Printed Name ___________________________ | |
| Certifier's Seller's Permit Number: ___________________________ | |
| Certifier's Business Name and Address* | ___________________________ |
| ___________________________ | |
| ___________________________ | |
| ___________________________ | |
| Certifier's Telephone Number | ___________________________ |
*Please Note: The certifier must be registered to do business at the location of the retailer upon whose premises they are making retail sales.
Cal. Code Regs. Tit. 18, div. 2, ch. 4, art. 18, app A