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Legal Business Name:

Trade Name/ Doing Business As:

Country

State

Legal form of business

Enter your Federal Tax Id/EIN

Select your identification number

Enter your Identification number here

State Resale License Number:(Also Attach Copy)

Phone

Local Representative:

Annual Sales:

# of Employees:

Business Since:

Duns#:

Brand(s) you are interested in reselling:

Vertical Market(s): (AV, Sound Cont., MI, etc.)

Company Website

Address

Billing Street

Billing City

Billing state

Ex.Massachusetts

Billing zip

Is your shipping address different than your billing address ?

YesNo

Shipping Street

Shipping City

Shipping State

Shipping Zip

Contacts

Contact 1 - Purchasing

First Name

Last Name

Phone

Contact 2 - Payables

First Name

Last Name

Phone

Contact 3 - Sales Manager/Other

First Name

Last Name:

Phone

Company Ownership/Officers

First Officer/Owner/Principal
Note: The email address entered here will receive an email for electronic signature via DocuSign.

First Name

Last Name:

Title

Share of Ownership:

Direct Phone:

Mobile:

Second Officer/Owner/Principal
Note: The email address entered here will NOT receive an email for electronic signature via DocuSign.

First Name

Last Name:

Title

Share of Ownership:

Direct Phone:

Mobile:

Requested Terms:

Terms Type

Amount of Credit Requested:

Company Total Assets:

Company Total Liability:

Have you or your officers ever filed a petition for bankruptcy?

YesNo

Is your company subject to any litigation?

YesNo

If so, describe

Please add your current/previous year financials and/or tax returns( Only add if requested credit more than $80,000 )

Trade References:

Please fill out trade references completely; missing information will delay the processing of your application. Email speeds up response.

Trade Reference 1

Name:

State:

Phone

Account #:

Trade Reference 2

Name:

State:

Phone

Account #:

Trade Reference 3

Name:

State:

Phone

Account #:

Trade Reference 4

Name:

State:

Phone

Account #:

The information provided is supplied with the intention of becoming an authorized reseller, and I do hereby certify that this information is true, correct, current and complete. I authorize Starin Marketing, Inc. to make such credit investigation as Starin Marketing, Inc. sees fit, including information concerning the financial and credit history of my company and myself:

I hereby agree to the terms and conditions listed on the attached page.

Please attach your State Resell certificate

We need the following information to complete your Form ST105

SECTION 1

Instructions to complete the section

A) This section requires an identification number. In most cases this number will be an Indiana Department of Revenue issued Taxpayer Identification Number (TID - see note below) used for Indiana sales and/or withholding tax reporting. If the purchaser is from another state and does not possess an Indiana TID Number, a resident state’s business license, or State issued ID Number must be provided.

B) Exceptions - For a purchaser not possessing either an Indiana TID Number or another State ID Number, the following may be used in lieu of this requirement.

Federal Government – place your FID Number in the State ID Number space.

Farmer – place your SSN or FID Number in the State ID Number space.

Public transportation haulers operating under another motor carrier authority, or with a contract as a school bus operator, must indicate their SSN or FID Number in the State ID Number space.

Nonprofit Organization – must show its FID Number in the State ID Number space.

Provide your Indiana Registered Retail Merchant’s Certificate TID and LOC Number as shown on your Certificate.

TID Number ( 10 digits):

LOC Number ( 3 digits):

If not registered with the Indiana DOR, provide your State Tax ID Number from another State

*See instructions on the reverse side if you do not have either number.

State of Issue:

State ID number:

SECTION 2

Instructions to complete the section

A) Purchaser must check the reason for exemption.

B) Purchaser must be able to provide additional information if requested.

Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain)
Sales to a retailer, wholesaler, or manufacturer for resale only

Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain)

Sales to retailer, wholesaler, or manufacturer for resale onlySale of manufacturing machinery, tools, and equipment to be used directly in direct production.Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin #10. (May not be used for personal hotel rooms and meals)Sales of tangible personal property predominantly used ( greater than 50 percent) in providing public transportation. A person or corporation who is hauling under someone else's motor carrier authority, or has a contract as a school bus operator, must provide their SSN or FID Number in lieu of a State ID Number in lieu of a State ID Number in Section 1.Sales to persons, occupationally engaged as farmers, to be used directly in production of agricultural products for sale. Note: A farmer possessing a State Business License Number may enter a FID Number or a SSN in lieu of a State ID Number in Section 1.Sales to a contractor for exempt projects ( such as public schools, government, or nonprofits).Sales to Indiana Government Units (agencies, cities, towns, municipalities, public schools, and state universities).Sales to the United States Federal Government. Note: A U.S Government agency should enter its Federal Identification Number(FID) in Section 1 in lieu of a State ID Number.Other.

USDOT Number :

Agency name:

Explain

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We need the following information to complete your Form ST105

Instructions to complete the section

Instructions to complete the section

Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain)Sales to a retailer, wholesaler, or manufacturer for resale only

Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain)
Sales to a retailer, wholesaler, or manufacturer for resale only