Non-Participating Tobacco Product Manufacturer Brand Identification

Form NPM 002 (Rev. 0/201) NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER BRAND IDENTIFICATION FORM (Copy this form and attach for each additional brand) Pursuant to R.C. 1346.02 and 1346.05 and Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 The non-participating manufacturer identified in Part 1 of the Certificate of Compliance has the following brand, which the tobacco product manufacturer affirms is deemed its cigarette or RYO tobacco for purposes of R.C. 1346.02 and 1346.05. Please note that pursuant to R.C. 1346.05(A)(4)(b) the Attorney General retains the discretion to determine that the cigarettes or RYO tobacco in a brand family constitute the cigarettes of another tobacco product manufacturer. Complete for each brand sold in the 201 calendar year and at any time in the1.Non-Participating Manufacturer Name: 2.Brand Identification and Sales Information 2a. Brand Name: 2b. Cigarettes or Roll-Your-Own: CIGARETTE RYO 2c. Total units of this brand sold in Ohio for 201: NOTE: .09 OZ OF RYO CONSTITUTES ONE UNIT 2d. Is this brand currently being sold in Ohio as of the date of this certification? Yes No 3.If the factory address is complete 3a through 3e below: 3a. Factory Address: 3b. Factory Phone N: 3c. Factory Fax N: 3d. Factory Manager?s Name: 3e. Manager?s Phone No.: 4.If this brand was previously manufactured by another entity, provide the names and addresses of such manufacturers4a. Name of Previous Manufacturer: 4b. Address of Previous Manufacturer: 5.Contract Manufacturing Information for the brand listed in 2a of this form: Any manufacturing agreement to the Tobacco Product Manufacturer to manufacturer this brand must be included. 5a. Effective Date of Agreement: 5b. Expiration Date of Agreement: 6.Federal Requirements (CIGFor the brand family identified in Part 2a of this form, provide a copy of the current Federal Trade Commission (FTC) letter, authorizing this brand?s health-warning rotation plan. 6a. FTC Effective Date: 6b. FTC Expiration Date: 6c. Plan submitted to FTC by: 6d. Relationship to Manufacturer: For the brand family identified in Part 2a of Centers for Disease Control (CDC) letter, approving this brand?s ingredient listing. 6a. CDC Effective Date: 6b. CDC Expiration Date: 6c. List submitted to CDC by: 6d. Relationship to Manufacturer: 7.Trademark Information for the brand listed in 2a of this form: Any license agreement or other document providing permission 7a. Name of Trademark Owner: 7b. Address of Trademark Owner: 7c. Registration and/or Serial Number of Trademark: 8.Compliance with the Ohio State Fire Marshal?s Proof of ?Reduced Ignition Propensity? Certification 8a. Certification has been submitted to the Ohio Fire Marshal and is: Currently Listed Pending Approval 8b. Date of Fire Marshal?s Approval: 8c. Expiration date of Certification: Attach Manufacturing Agreement Attach FTC/CDC Letters Attach License Agreement Click to Copy This Form