N.Y. Comp. Codes R. & Regs. tit. 20, § 62.1
(e) Every such permittee who, pursuant to this section, sells alcohol tax-free is required to obtain from the purchaser a certificate in the following form:
The undersigned engaged in the business of ________ certifies that all alcohol purchased tax-free from ________ and to be purchased hereafter, has been or will be used by the purchaser exclusively for the following nonbeverage purpose or purposes:
(Purchaser)
By
(Title)
Purchaser's N.Y. IAP No. N.Y. AP No. N.Y. DAA No. N.Y. DAB No. N.Y. DAC No. N.Y. DAD No.