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Certification For Listing In The Connecticut Tobacco Directory TPM-2 - Connecticut
| Certification For Listing In The Connecticut Tobacco Directory Form. This is a Connecticut form and can be used in Cigarette And Tobacco Products Taxes Department Of Revenue Services Statewide . |
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State of Connecticut Form TPM-2 Certification for Listing in the Connecticut Tobacco Directory as of July 1, 2011 (Rev. 03/11) This application will not be processed or considered complete until all the information and documents required, either by the application form, the instructions to the application form, or by the request of the Department of Revenue Services (DRS) or the Office of the Attorney General have been submitted. Initial Supplemental Complete this form in blue or black ink only. Part I: General Business and Ownership Information For completion by participating manufacturers (PMs) and nonparticipating manufacturers (NPMs) 1. Applicant tobacco product manufacturer identification Applicant: _______________________________________________________________________________________________ Street address: ___________________________________________________________________________________________ _______________________________________________________________________________________________________ Mailing address if different from above: ________________________________________________________________________ _______________________________________________________________________________________________________ Telephone number:_________________________________Facsimile (Fax) number: ___________________________________ Email address: ___________________________________________________________________________________________ Website address: _________________________________________________________________________________________ Name and title of authorized officer completing this certification: ____________________________________________________ _______________________________________________________________________________________________________ Manufacturing plant(s) name and street address if different from above: ______________________________________________ _______________________________________________________________________________________________________ Manufacturing plant telephone number: ________________________________________________________________________ Manufacturing plant fax number: _____________________________________________________________________________ Name, title, and telephone number of contact person at plant if different from above: ____________________________________ Attach additional sheet(s) as necessary to provide a complete response. Attach a photograph or diagram of the manufacturing (fabricating) facility and indicate on the photograph or diagram where the equipment and facilities for manufacturing the cigarettes, if any, are located. 2. The undersigned certifies that as of the date of this certification, the applicant named above is a (initial one): ___ ___ Participating manufacturer (PM) as the term is defined in Section II(jj) of the Master Settlement Agreement (MSA) that has in the past generally performed and is currently generally performing its financial obligations under the MSA. Nonparticipating manufacturer (NPM) that is in full compliance with Conn. Gen. Stat. §4-28i and implementing regulations including having made all required deposits into a qualified escrow fund for all the years beginning with calendar year 2000. 3. The applicant is the manufacturer (fabricator) of all of the brand families listed in this certification which are intended to be sold in the United States, including cigarettes intended to be sold in the United States through an importer. Yes No American LegalNet, Inc. www.FormsWorkFlow.com 4. The applicant is the first purchaser anywhere for the resale in the United States of cigarettes manufactured anywhere that the manufacturer does not intend to sell in the United States. Yes No If the answer is Yes, identify each cigarette manufacturer (fabricator), the plant street address, mailing address, contact person, telephone and fax numbers, and the relationship to the applicant. Identify the location of the transfer of the ownership of the cigarettes and a copy of every agreement or contract between the applicant and the manufacturer. Attach additional sheet(s) as necessary to provide a complete response. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 5. The applicant is a successor of an entity described in Question 3 or Question 4 above. Yes 6. No If the applicant answered No to Questions 3, 4, and 5 above, explain the basis for the applicant's claim that it is the tobacco product manufacturer as defined in Conn. Gen. Stat. §4-28h for each of the brand families listed in this certification, and submit all documentation to support the applicant's claim. If, for example, the applicant seeks to list brand families that are contract manufactured by other participating manufacturers, explain and document those arrangements. Attach additional sheet(s) as necessary to provide a complete response. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 7. Since January 1, 2010, has there been a change in manufacturer (fabricator) of one or more of the brand families listed in this application form? Yes No Former Manufacturer Current Manufacturer If the answer is Yes, identify
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