NPM Information Request

Certification Year: State of Tennessee Office of the Attorney General and Reporter Revenue Section Tobacco Enforcement Division Post Office Box 20207 Nashville, TN 37202-0207 NPM Information Request Pursuant to Tenn. Code Ann. §§ 67-4-2601 et seq. __________ Please type or legibly print in permanent blue ink. Use additional pages as necessary. (This Form may be filled out on-line; however, all signatures must be executed in permanent blue ink.) Applicant name: Street Address: City/State/Zip/Country: Mailing Address (if different from above): City/State/Zip/Country: Telephone number: E-mail address: Facsimile number: The following documents must be attached to this certification application. Initial by each number to confirm that each document requested is attached and labeled appropriately: 1. Samples - Samples (or legible, identical size, color copies of all sides of the packaging thereof) of the current packaging and labeling used for each of the individual brands within each Brand Family listed in Part 3 of the Certification Form for Listing on Tennessee's Directory. Initial to confirm that you have attached these documents. Permits & Licenses to Manufacture Cigarettes - A copy of all permits, licenses or other authorization to manufacture tobacco products issued by any governmental entity, whether located in the United States or elsewhere. This includes importer's certificate, trademark holder's certificate, etc. Initial to confirm that you have attached the requested documents. Certificate of Compliance (cigarettes only) - A copy of the current Centers for Disease Control (CDC) ingredient-listing compliance letter(s) pertaining to the brands listed in this certification and a copy of the letter sent to the CDC from the manufacturer seeking approval for cigarette 2. 3. Revised January 2016 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com NPM Information Request brand families (trade secret ingredients may be redacted) submitted for each approval letter. Initial to confirm that you have attached the requested documents. 4. FTC Warning Rotation Information (cigarettes only) - A copy of the complete current health warning rotation plan submitted to the Federal Trade Commission ("FTC") pursuant to 15 U.S.C. § 1333 and a copy of the approval letter from the FTC for each brand family applicant wants listed. If the Certification Applicant sells or intends to sell cigarettes that are not made in the United States, please identify the name and address of the entity that submitted the ingredient reporting information to the U.S. Secretary of Health and Human Services. Initial to confirm that you have attached these documents. Brand List - Provide a complete list of all tobacco product Brand Families, (including all cigarettes, roll-your-own, cigars, little cigars, pipe tobacco, smokeless tobacco, etc.) currently and previously manufactured by the (Non-Participating) Manufacturer, its principals, subsidiaries, affiliates, successors, members, officers, owners and directors. This list is in addition to the list provided for certification. List whether or not sold in the U.S., the dates during which each Brand Family is, or was, manufactured, and place of manufacture for those brands. Initial to confirm that you have attached these documents. Trademark Information - A list of the trademark owners, including street address and telephone number for each Brand Family identified in the Certification for Listing on Tennessee's Directory. Proof of current ownership (or assignment of the rights to) trademarks for all brand families for which the company is seeking certification for must also be attached. Initial to confirm that these documents are attached. Trademark Holder's Certificate - A copy of the trademark holder's certificate under penalty of perjury that it has not withdrawn consent to import into the United States as required by 19 U.S.C. 1681a(c)(3)(A), or a copy of the importer's certificate under penalty of perjury that the trademark owner has not withdrawn consent to import into the United States as required by 19 U.S.C. 1681a(c)(3)(B). Initial to confirm that these documents are attached. Photographs ­ Provide four clear color photographs of the exterior of each side of your manufacturing facilities. The photographs must have been taken within 90 days of the date of this application, and measure at least four inches by six inches. Each of the photographs must provide clear and unobstructed views of each side of the outside of the manufacturing facility. Each photograph must be labeled on the back with the name of the factory, the full street address of the factory, the date of the photograph was taken and the full name, address and telephone number of the person who took the photograph. Provide five clear color photographs of the interior of each manufacturing facility. The photographs must provide at a minimum the following: (a) clear and unobstructed views of the majority of the interior of the manufacturing facility, (b) clear and unobstructed views of the number of manufacturing lines and machines in operation in the manufacturing facility, (c) clear and unobstructed views of the manufacturing facility in operation, and (d) clear and unobstructed views of the number of employees normally working in the manufacturing facility when it is in operation. Each photograph must have been taken within 90 days of this application, measure at least four inches by six inches, and be labeled on the back with the name of the factory, the full street address of the factory, the date of the photograph was taken and the full name, address and telephone number of the person who took the photograph. Initial to confirm that all photographs are attached. 5. 6. 7. 8. a) b) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com NPM Information Request 9. Notice of Appointment of Registered Agent ­ Attach the official Notice of Appointment of Registered Agent Form. This form may be found on the Attorney General's website. Also submit a current letter (dated this year) from the registered agent accepting this appointment. Initial to confirm that both the form and acceptance letter are attached to this form. Stamping Agent and/or Distributor ­ For each stamping agent or distributor of your products possessing a Tennessee wholesale license, please provide the name, address, telephone, facsimile numbers and all brand families delivered to each stamping agent or distributor. Initial to con