Non-Participating Manufacturer Certification Form

STATE OF WYOMING TOBACCO PRODUCT MANUFACTURER CERTIFICATION FOR LISTING ON THE DIRECTORY UNDER WYO. STAT. §§ 9-4-1201 THROUGH 1202; AND 9-4-1205 THROUGH 1210 SALES YEAR 2016 (DUE ON OR BEFORE APRIL 30, 2017) I. INTRODUCTORY INFORMATION Please provide the following information for brands being certified in the State of Wyoming. Attach additional sheets, as needed, to provide complete responses. Failure to fully complete the Certification and provide all requested documentation may result in delay or denial of certification. Further information regarding the certification process can be found in the Tobacco Certification and Directory Rules, which are posted on the Wyoming Secretary of State website: http://soswy.state.wy.us/Rules/default.aspx. II. APPLICANT INFORMATION A. Applicant is: A Participating Manufacturer under the Tobacco Master Settlement Agreement (MSA). A Nonparticipating Manufacturer as defined in Wyo. Stat. Ann. § 9-4-1210(a)(vi). B. Name of Applicant: C. Contact Person: _______________________________________________________________ D. Physical Address: E. Mailing Address: F. Website Address(es): G. Telephone Number: ____________________________________________________________ H. Facsimile Number: ____________________________________________________________ I. E-mail Address: _____________________________________________________________ J. Name/Title of Person(s) Completing this Certification form: _____________________________ v2016.6 page 1 American LegalNet, Inc. www.FormsWorkFlow.com K. Please provide the name and contact information for a designated representative authorized to respond to any questions from the Wyoming Attorney General's office regarding this certification. ___________________________________________________________________________________________ ___________________________________________________________________________________________ L. Please attach the Applicant's organizational documents. Check here if you have already provided the organizational documents. It is not necessary to provide organizational documents that have already been provided to the Wyoming Attorney General's office. M. Please list all officers of the Applicant and all persons with an equity interest of 10% or more in the Applicant. Attach additional sheets, as needed, to provide a complete response. Check here if you have already provided the list of officers and equity owners. It is not necessary to provide that information if it has already been provided to the Wyoming Attorney General's office. Name Title Equity Interest Address Telephone Number Email Address N. If located in the U.S., Applicant Manufacturer's Federal Taxpayer ID: O. Has the Applicant, directly or through a retailer, distributor or similar intermediary, participated in the direct sale of its Cigarettes to customers via catalog, the Internet, by phone or by mail? Such participation includes the sale of Applicant's Cigarettes to a retailer that in turn sells directly to customers via catalog, the Internet, by phone or by mail. Please select Applicant's response from those presented below or provide an explanation as to why none apply: The Applicant directly sells its Cigarettes to customers via catalog, the Internet, by phone and/or by mail. If Applicant sells its products via the Internet, please provide the website address for the site(s) at which its products are sold and a copy of the Applicant's online sales policy. Attached as Exhibit ____. ____________________________________________________________________ The Applicant provides its Cigarettes to retailers and/or distributors which sell directly to customers via catalog, the Internet, by phone and/or by mail. If so, please provide the name, website address, physical mailing address, and telephone number for all such retailers. ____________________________________________________________________ The Applicant does not participate, directly or through a retailer, distributor or similar intermediary, in the direct sale of its Cigarettes to customers via catalog, the Internet, by phone and/or by mail. v2016.6 page 2 American LegalNet, Inc. www.FormsWorkFlow.com III. CIGARETTE REQUIREMENTS A. Please check here if the Applicant is only certifying RYO tobacco brands and go to question III.(E). Applicant is certifying RYO tobacco brands only. B. FIRE SAFE - Provide a copy of the current certification from the Wyoming State Fire Marshal's office for each brand being certified as required by the Wyoming Reduced Cigarette Ignition Propensity Act. Attached as Exhibit ___. Note that FSC certification from the Wyoming Department of Revenue must be obtained prior to requesting that a cigarette brand be listed in the Directory. C. INGREDIENT LIST - Provide a copy of the current Centers for Disease Control "Certificate of Compliance" or similar letter approving the ingredient list for cigarettes for the brand families sold in the State of Wyoming. Attached as Exhibit ___. D. ROTATION PLAN ­ Provide a copy of the current Federal Trade Commission letter authorizing the health warning rotation plan for the brand families sold in the State of Wyoming. Attached as Exhibit ___. E. JENKINS/PACT ACT ­ For each of the past 12 calendar months, has the Applicant provided the reports required by 15 U.S.C. § 375 et seq. to the Wyoming Department of Revenue? Yes No Provide a copy of the current PACT Act registration. Attached as Exhibit ___. If Pact Act registration is not required, please explain why. _____________________________________ ____________________________________________________________________________________ F. TTB NUMBER - List Applicant's U.S. Treasury, Tobacco Tax Bureau Permit Number as a manufacturer and as an importer: Manufacturer _______________________ Importer___________________________ Provide a copy of the current TTB tax permit(s). Attached as Exhibit ___. G. WYOMING DEPARTMENT OF REVENUE CIGARETTE AND TOBACCO LICENSE ­ Provide the Applicant's Wyoming Department of Revenue cigarette and tobacco license number issued under Wyo. Stat. Ann. § 39-18-106. ____. v2016.6 page 3 American LegalNet, Inc. www.FormsWorkFlow.com IV. BRANDS AND STYLES A. BRANDS AND STYLES Currently Certified Manufacturers ­ Please print off the Wyoming Tobacco Directory page(s) for your brands. Put a check mark beside each brand and style that is being certified in the State of Wyoming for the current year. Identify with an asterisk any brand or style sold in the state d