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Notice Of Appointment Or Registered Agent And Registered Agents Statement TPM-4 - Connecticut
| Notice Of Appointment Or Registered Agent And Registered Agents Statement 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-4 Notice of Appointment of Registered Agent and Registered Agent's Statement (Rev. 03/06) Complete this form in black or blue ink only. Sign, date, and return original to: Office of the Attorney General Finance Department PO Box 120 Hartford CT 06141-0120 The undersigned Nonparticipating Manufacturer (NPM), __________________________________________________________, hereby appoints_________________________________________________________________as its registered agent. Said registered agent is authorized to receive service of process on behalf of the NPM. The NPM agrees to do the following: (1) provide notice to the Office of the Attorney General of the State of Connecticut (Attorney General) at least 30 calendar days prior to termination of the authority of the registered agent; and (2) provide proof to the satisfaction of the Attorney General of the appointment of a new agent at least five calendar days prior to the termination of the existing agent appointment. The NPM further agrees that if the agent terminates its agency appointment, the undersigned will provide notice to the Attorney General of the termination within five calendar days and will include proof to the Attorney General of the appointment of a new agent. I hereby certify and declare that all of the statements and information contained in this Notice of Appointment, including but not limited to any accompanying statements or attachments, are true and complete and that I am a person authorized to bind the NPM making this Notice of Appointment either under the laws of Connecticut or of the jurisdiction where the manufacturer resides or is organized. The failure to file this form is a basis for removal of the undersigned NPM and its brand families from the Connecticut Directory. This Notice of Appointment must be signed and dated in the presence of a notary public. Signature of Authorized Representative for NPM: ________________________________________________________________ Authorized Representative (Print Name): _______________________________________________________________________ Title: ______________________________________________________________________________________________________ Principal Place of Business (physical address): _________________________________________________________________ State of County of Country of ) ) ) On _____________________________________ , before me, _________________________________________________ , personally appeared _______________________________________________ , personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he or she executed the same in his or her authorized capacity, and that by his or her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal. Signature ________________________________________________________________________________________________ My Commission expires: ____________________________________________________________________________________ IMPORTANT: Registered agents must complete and sign the statement on the back of this form. American LegalNet, Inc. www.FormsWorkFlow.com Name and Address of Registered Agent: Name: ____________________________________________________________________________________________________ Street Address (Required--must be within the state of Connecticut): __________________________________________________ _________________________________________________________________________________________________________ PO Box (If applicable): _______________________________________________________________________________________ City and State: _________________________________________________ ZIP Code: ___________________________________ Telephone: _______________________________________________ Fax Number: _____________________________________ E-mail address: ____________________________________________ I consent to serve as the Registered Agent in the state of Connecticut for the above-named NPM, pursuant to Conn. Gen. Stat. ยง4-28n. I understand it will be my responsibility to receive Service of Process on behalf of the NPM; to forward mail to the NPM; and to immediately notify the Office of the Attorney General if I resign or change the office address of the Registered Agent. This Notice of Appointment must be signed and dated in the presence of a notary public. Signature: ___________________________________________________ Date: _______________________________________ Print Name: ________________________________________________________________________________________________ Title: _____________________________________________________________________________________________________ State of County of Country of ) ) ) On _____________________________________ , before me, _________________________________________________ , personally appeared _______________________________________________ , personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he or she executed the same in his or her authorized capacity, and that by his or her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal. Signature ________________________________________________________________________________________________ My Commission expires: ____________________________________________________________________________________ Form TPM-4 Back (Rev. 03/06) American LegalNet, Inc. www.FormsWorkFlow.com
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