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North Dakota Office Use Only Application For Sales Tax Exemption Certificate Office of State Tax Commissioner Sales & Special Taxes 600 E. Boulevard Ave., Dept. 127 Bismarck, ND 58505-0599 See the Exempt Organizations guideline for more detail about organizations that qualify for a sales tax exemption on purchase transactions. This application should be filed only by federal, state, local or tribal governments; federal corporations; schools; hospitals, nursing homes, intermediate care facilities, basic care facilities, and emergency medical service providers licensed by the State Department of Health; voluntary health associations recognized by the National Health Council; and assisted living facilities licensed by the Department of Human Services. Name of Organization Name Federal Identification Number (FEIN) Phone Number Location Street Address City State Zip Code Mailing Address (If Different From Above) PO Box or Street Address City State Zip Code  Federal Government State County or Township City Native American Tribal Gov’ts Voluntary Health Association Type of  Public or Private School, College or University Organization  Intermediate Care Facility (ND Department of Health license no. _______________)  Assisted Living Facility (ND Human Services license no. _______________)  Basic Care Facility (ND Department of Health license no. _______________)  Emergency Medical Services Provider (ND Department of Health license no. _______________)  Hospital (ND Department of Health license no. _______________)  Skilled Nursing Facility (ND Department of Health license no. _______________) (Check One)  Provide explanation of primary function of organization (1) Does the organization hold a sales and use tax permit? (2) Does the organization make any retail sales?   Yes Yes   No No Authorized Purchasing Agent ________________________________________________________________________________ Name Title Phone Number I certify that the above statements are correct to the best of my knowledge and belief and that I am authorized to sign this application. Signed _________________________________________ Title ________________________________________ Print Name ______________________________________ Date ________________________________________ IMPORTANT: The Certificate of Exemption, if granted, applies to purchases only. It does not apply to the sale of tangible personal property. As soon as your application is approved, a Certificate will be mailed. This certificate must be retained by you and a copy of your certificate must be furnished to all suppliers or retailers at the time of purchase. 21919 (Rev. 5/09) Phone: 701-328-1246 Fax: 701-328-0336 E-mail: salestax@nd.gov Web site: www.nd.gov/tax