The undersigned engaged in the business of ________ certifies that all alcohol purchased tax-free from ________ and to be purchased hereafter, has been or will be used by the purchaser exclusively for the following nonbeverage purpose or purposes:____________
(Purchaser)
By ____________
(Title)
Purchaser's N.Y. IAP No. ____________
N. Y. AP No. ____________
N. Y. DAA No. ____________
N. Y. DAB No. ____________
N. Y. DAC No. ____________
N. Y. DAD No. ____________
N.Y. Comp. Codes R. & Regs. Tit. 20 § 62.1