OFFICE OF STATE TAX COMMISSIONER
                                             Important:  Click this button to reset the form
CONTRACTOR’S CERTIFICATE
SFN 21946 (11-2002)

I, the undersigned, am a construction contractor holding North Dakota Contractor's License No.______________
issued by the Secretary of State of the State of North Dakota and North Dakota Sales and Use Tax Permit
number __________________ assigned to me by the State Tax Commissioner of the State of North Dakota.

I certify that as a construction contractor, I will report and remit any sales or use tax due as a result of purchases made
by me from ______________________ (Seller) directly to the North Dakota Office of State Tax Commissioner.

Dated this _____ day of _________________, ________ at ___________________________  _____________
             (Date) (Month) (Year)                    (City) (State)

____________________________________________ ____________________________________________
(Contractor)                                 (Address)

                                             Important:  Click this button to reset the form