Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Beer Displays on Floor *

Yes

No

Price Specials *

Yes

No

Draft Account *

Yes

No

Decision Maker Availability

Monday

Tuesday

Wednesday

Thursday

Friday

First Delivery Needed by

MM

DD

YYYY

Payment Method *

Fintech

ACH/Direct Withdrawal

COD

This is a blanket purchase exemption request *

Yes

Purchaser must indicate the type of exemption being claimed for this purchase. *

Sales to a retailer, wholesaler, or manufacturer for resale only.

Digital Signature of Purchaser *

First Name

Last Name

Date *

MM

DD

YYYY

I hereby certify under the penalties of perjury that the property purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act, Indiana Code 6-2.5, and the item purchased is not a utility, vehicle, watercraft, or aircraft. I confirm my understanding that misuse, (either negligent or intentional), and/or fraudulent use of this certificate may subject both me personally and/or the business entity I represent to the imposition of tax, interest, and civil and/or criminal penalties.: *

Confirm

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number *

(###)

###

####

Decision Maker Availability

Monday

Tuesday

Wednesday

Thursday

Friday

First Delivery Needed by

MM

DD

YYYY

Payment Method *

Fintech

ACH/ Direct Withdrawl

COD

This is a blanket purchase exemption request *

Yes

Purchaser must indicate the type of exemption being claimed for this purchase *

Sales to a retailer, wholesaler, or manufacturer for resale only

Digital Signature of Purchaser *

First Name

Last Name

Date *

MM

DD

YYYY

I hereby certify under the penalties of perjury that the property purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act, Indiana Code 6-2.5, and the item purchased is not a utility, vehicle, watercraft, or aircraft. I confirm my understanding that misuse, (either negligent or intentional), and/or fraudulent use of this certificate may subject both me personally and/or the business entity I represent to the imposition of tax, interest, and civil and/or criminal penalties.: *

Confirm

Type of Event *

Special Event

Brewfest

Date of Event *

MM

DD

YYYY

Event Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Name *

First Name

Last Name

Contact Phone Number *

(###)

###

####

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country