Fill and Sign the Form 3372 Michigan Sales and Use Tax Certificate of

Kent County Office (302) 744-1220 Fax (302) 739-1957 MATTRESS, PILLOW AND BEDDING PROGRAM TITLE 16 DELAWARE CODE CHAPTER 21 APPLICATION FOR INITIAL PERMIT AND PERMIT RENEWAL TO MANUFACTURE OR SHIP BEDDING PRODUCTS INTO DELAWARE Answer all questions and return to: (Print legibly) EHFS – KC THOMAS COLLINS BUILDING SUITE 5 540 S. DUPONT HWY DOVER, DE 19901 1. Legal name of business to appear on permit: Address to mail permit (include business name if different from above): 2. Do you manufacture bedding products? YES___* NO___ If YES: list physical location (City, State, Country) of bedding manufacturing sites: 3. Do you distribute bedding products manufactured by others? YES___* NO___ If YES, list the Business Names and Locations of suppliers whose products you distribute. (Use extra sheets if needed.) 4. List types of bedding products shipped into Delaware: ► Attach one (1) Law Label bedding tag with Uniform Registry Number (URN) - For both Initial and renewal. No permit will be issued without an original law label attached to application. URN_____________ ■ Each different Uniform Registry Number requires a separate permit application and $50 fee. ■ Make additional copies of this application as needed. ► Enclose check or money order in amount of $50. US payable to STATE OF DELAWARE 00 ATTENTION OVERSEAS COMPANIES: Enclose money order or bank draft with US DOLLARS IMPRINTED ON THE MONEY ORDER OR BANK DRAFT. Payments with hand-written US Dollar amounts cannot be accepted from outside U.S. Check No. Contact Information: (Please print legibly and sign in ink) Name of person to whom permit will be sent: Phone No & Extension__________________________________ Fax No. Note: This office cannot place telephone calls or send faxes outside U.S. E-MAIL Address: Date: __________________________ Signature of Applicant: Applicant - Do not write below the dotted line Date Approved: ____________ Date Permit Issued:_____________ Bedding Permit Number___________________ Signature of Official: _______________________________________ PAID STAMP: _________________________ ENVIRONMENTAL HEALTH FIELD SERVICES – KENT COUNTY  THOMAS COLLINS BUILDING, SUITE 5 540 SOUTH DUPONT HIGHWAY  DOVER  DELAWARE  19901