Customer Registration Form

Firm Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I hereby certify, That I hold valid seller's permit number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Issued pursuant to the Sales and Use Tax Law: that I am engaged in the business of selling

Type of Business_______________________________________________________________________

that the tangible personal property described herein which I shall purchase from Shinoda Design Center will be resold 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 uderstood that I am required by the Sales and Use Tax Law to report and pay for the tax measured by the purchase price of such property.

Description of property to be purchased___________________________________________________________________________

Use of Purchase, Check One:                     ___ Resale ___ Display (Taxable)

Business Categories: Please Check One:

___1. Florist Shop   ___2. Floral Designer   ___3. Interior Design Studio   ___4. Interior Designer   ___5. Display

___6. Gift Store   ___7.Manufacturer/Assembler   ___8. Restaurants/Caterer   ___9. Other____________

Do you want to receive mailers? ___Yes ___No

Do the mailers need to be to the attention of anyone? ___Yes ___No

To the attention of?___________________________________(Name or Department)

Additional Buyers_________________________________________________________________________________


City____________________________________________ State______________ Zip________

Phone______________________________ Fax_________________________________

Email Address:________________________________________________

Drivers License#______________________________

Signature_________________________________________ Date:______________ 20________

Print Name________________________________________ Title_________________________
Mail or fax this form with a copy of your business and/or resale license to:

601 W Dyer Road
Santa Ana, CA 92707
Phone (714) 541-4444
Fax (714) 541-0282

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