Print the form, complete all
spaces and fax
to 817-370-1957
If you have questions, contact ACI at 817-370-9515
Account Application
This form must be filled out COMPLETELY and include an authorized signature
to establish an account with ACI.
Allow 2-3 working days for verifying Tax information and activating the
account.
Please PRINT or TYPE
Shipping Address: (if different from above)
Type of Business
Purchaser hereby Certifies to Seller that:
1. Purchaser holds a valid Permit, number _________________________ issued under the Limited
Sales Excise and use Tax Act of the State of _____ which permit has not been revoked or suspended.
2. That the undersigned hereby claims an exemption from payment of Taxes under Chapter 20,
Title 122A, Revised Civil Statutes of Texas, on the tangible personal Property purchased from
you since September 1, 1961, and on each order that we shall hereafter give you, unless such
order otherwise specifies, and until this notice is revoked by us in writing.
3. The reason the said purchaser is claiming exemption is: ___ Resale ___Non-Profit ___Other___
Please explain if "Other": _____________________________________________________________________________
4. The General character of the tangible personal property sold, leased or rented by the purchaser in the
regular course of business is: (please explain): ________________________________________
5. The purchaser will be liable for payment of the Limited Sales and Use Tax, if the purchaser uses the
tangible personal property in some other manner or for some other use than the reason listed above and
shall pay the tax based on the price paid for the Tangible Personal Property.
Signature: ______________________________ Title __________________ Date ___________
Print this form, complete all spaces, and fax to 817-370-1957