Virginia > Statewide > Office Of Attorney General > Tobacco Section
Tobacco Product Manufacturer Certification TT-19 PM - Virginia
| Tobacco Product Manufacturer Certification Form. This is a Virginia form and can be used in Tobacco Section Office Of Attorney General Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
FORM TT-19 PM COMMONWEALTH OF VIRGINIA Certification Application for Participating Tobacco Product Manufacturers (PM) Note: All fields must be filled in and all attachment/supporting documentation must be included with the certification application before it will be considered for review. Part 1: Type of Certification Application: _____ Initial Certification Application for Sales Year: __________ _____ Annual Certification Application (Due in the Office no later than April 30) for Sales Year: __________ _____ Supplemental Certification Application (Due 30 days prior to any desired change in previously approved Certification Application) Part 2: TPM Identification: Full Legal Name: ________________________________________________________ Federal Employers Identification Number: _____________________________________ Federal Tobacco manufacturer Permit Number: _________________________________ Contact Name: _________________________ Title: _____________________________ Physical Address: _________________________________________________________ __________________________________________________________________ __________________________________________________________________ Mailing Address: _________________________________________________________ __________________________________________________________________ Phone Number: ________________________ Fax Number: _______________________ Email Address: ________________________ Web Address: ______________________ Initial _____ Date ________ American LegalNet, Inc. www.FormsWorkFlow.com Rev. (12/09) 1 of 4 Form TT-19 PM If the Tobacco Product Manufacturer is represented by outside counsel for the purpose of compliance with Va. Code § 3.2-4200 et seq., provide the following: Name: Firm: Address: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Phone: Email: ___________________________ Fax: ____________________________ ____________________________________________________________ Part 3:Fabricator Identification: The TPM fabricates its own cigarettes: Yes ____ No _____ If the TPM is not the actual fabricator, provide the following: (attach additional pages if needed) Contact Name: Company Name: Physical Address: _______________________ Title: _________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ Mailing Address: ______________________________________________________ ______________________________________________________ Phone Number: Website Address: ___________________ Fax Number: _______________________ ______________________________________________________ Brand Family(s) contract manufactured for another company: (attach additional pages if needed) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Initial _____ Date ________ Rev. (12/09) 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Form TT-19 PM Part 4: Brand Families and Brand Styles the TPM seeks to certify: (attach additional pages if needed) Brand and Style Current Fabricator (if different from TPM) Previous Fabricator (if different from TPM) Initial _____ Date _____ Rev. (12/09) 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Form TT-19 PM Part 5: Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer) Under penalty of perjury, I state that (1) the Tobacco Product Manufacturer, as of the date of this Certification, is a Participating Manufacturer in full compliance with all applicable sections of Va. Code §§3.2-4200 through 3.2-4219; (2) I have examined this Certification, including attachments and supporting documents and, to the best of my knowledge and belief, this Certification, including attachments and supporting documents, is true, correct and complete; (3) I understand that the Tobacco Product Manufacturer is required to comply with state and federal laws concerning the sale of tobacco products; (4) I understand that the Attorney General may require additional information and/or documentation to determine if the Tobacco Product Manufacturer qualifies for listing in the Virginia Tobacco Directory; and (4) I am a qualified company officer authorized to bind the Tobacco Product Manufacturer making this Certification. Name: Phone: Email: Signature: Notary: City/County of _____________________, State and Nation of _____________________ Subscribed and sworn to before me on this date: Signature: My commission expires: ___________________________ Title: ___________________________ ___________________________ Fax: ___________________________ ___________________________________________________________ ___________________________ Date: ___________________________ Mail this original fully executed Certification and all attachments and supporting documents to: Office of the Attorney General Attn: Tobacco Section Office of the Attorney General 900 East Main Street Richmond, Virginia 23219 Additional Information is Available at: www.vaag.com; Legal and Legislative Reference Rev. (12/09) 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
