Nevada > Statewide > Attorney Generals Office > Tobacco Enforcement Unit
Participating Manufacturer Annual Certificate Of Compliance - Nevada
| Participating Manufacturer Annual Certificate Of Compliance Form. This is a Nevada form and can be used in Tobacco Enforcement Unit Attorney Generals Office Statewide . |
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CATHERINE CORTEZ MASTO ATTORNEY GENERAL STATE OF NEVADA Participating Manufacturer Annual Certificate of Compliance Please type or print. PART I: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION A. Complete company information below: Company Name Address City/State/Zip/Country Telephone Number Fax Number E-Mail Address Website Name/Title of Company Contact Address of Manufacturing Plant(s) Phone Number of Factory Fax Number of Factory If located in U.S.:Manufacturer's Federal Taxpayer ID number If located in US: TTB Tobacco Manufacturer Permit Number Expires Nevada Manufacturer License Number Date of Issuance Please check if contact information has changed since the last annual certification. Notes: (1) The contact information, including e-mail address, listed above will be used for all official correspondence coming from the Nevada Attorney General's Office. Please update this Office should contact information change during the course of the year. (2) Nevada wholesalers are only permitted to purchase unstamped product from a Nevadalicensed manufacturer or wholesaler. Therefore, most tobacco manufacturers must obtain a manufacturer's license from the Nevada Department of Taxation for their products to be legally sold in Nevada. Manufacturer's licenses are free of cost. If required, licensure must be obtained prior to this Office approving annual certification. NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 1 of 6 NVAGO 03-2012 American LegalNet, Inc. www.FormsWorkFlow.com PART II: BRAND FAMILY IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY) A. 2011 Brand Identification List all brand families sold by the manufacturer in 2011. By listing these brand families, the manufacturer, identified in Part I, affirms the listed brand families are to be deemed its cigarettes for the purposes of calculating its 2011 payments under the Master Settlement Agreement. Brand Family Name Cigarettes or RYO Cigarette RYO Brand Family Name Cigarettes or RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO B. Brand Identification for 2012 Directory Listing List all brand families intended for sale in Nevada during 2012. For each brand family, provide the date of Nevada fire-safe certification and the year during which the brand family was initially listed on the Nevada Tobacco Directory. If the brand family is not currently on the Nevada Tobacco Directory, a supplemental certification must be submitted. Brand Family Name Cigarettes or RYO Date of Brand Fire Safe Certification Year of Initial NV Directory Listing Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 2 of 6 NVAGO 03-2012 American LegalNet, Inc. www.FormsWorkFlow.com C. Brand Compliance with Federal and State Requirements 1. For all cigarette brand families intended for sale during 2012, provide a copy of the current Federal Trade Commission (FTC) approval letter for health-warning rotation plan. Additional information can be obtained at: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 General Information Telephone: 202-326-2222 http://www.ftc.gov 2. Provide a copy of the current Centers for Disease Control (CDC) ingredient-listing (cigarettes only) compliance letter(s) pertaining to the above brands of cigarettes for each approval letter. Additional information can be obtained at: Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Telephone: 1-800-311-3435 http://www.cdc.gov 3. For each brand family, provide a list of styles that will be sold in the State of Nevada. Notes: In 2010, the FDA banned style descriptors such as "bold" and "light." Out-dated style descriptors will no longer be listed on the Nevada Tobacco Directory. The list of styles to be sold in Nevada should not include out-dated style descriptors. If it is not clear what new style descriptors correspond with old style descriptors, please provide a chart or other documentation describing how the old and new style descriptors correspond. 4. If manufacturer is located within the United States, attach a copy of the manufacturer's current TTB permit. If the manufacturer is located outside of the United States, provide copies of any manufacturing or importer licenses, certificates, permits or similar documents issued by the country where the manufacturing takes place. 5. The non-participating manufacturer is the fabricator of all brand families for which 2012 certification is being sought (this includes cigarettes intended to be sold in the United States through an importer). Yes No If the non-participating manufacturer is not the fabricator of all brand families, on a separate sheet of paper provide the name and address of the fabricator of the brand families, and state fully the basis for seeking to have the brand families certified by the NPM applicant. Provide documentation to support your claims, including copies of every agreement between the NPM applicant and the fabricator. NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 3 of 6 NVAGO 03-2012 American LegalNet, Inc. www.FormsWorkFlow.com PART III: PACT ACT COMPLIANCE A. PACT Act Registration Has the manufacturer registered under the PACT Act with the ATF? Yes Has the manufacturer registered with the Nevada Department of Taxation? No Yes No If the answer to either of the above questions is no, please explain why the manufacturer is exempt from PACT Act registration requirements. (Attach additional sheets if necessary.) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ B. Registered Agent Information Name of Nevada registered agent Registered agent address City/State/Zip/Country Telephone Number Fax Number C. Monthly Shipping Reports Does the manufacturer ship product into Nevada? Yes No Has the manufacturer submitted all required PACT Act reports for 2011? Yes No List all known entities that shipped the manufacturer's product into Nevada in 2011. Attach additional sheets if necessary. Distributor Name Distributor Address Brand Distri
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