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NPM Appointment Of Registered Agent Form - Georgia
| NPM Appointment Of Registered Agent Form Form. This is a Georgia form and can be used in Tobacco Product Manufacturer Office Of Attorney General Statewide . |
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NON-PARTICIPATING MANUFACTURER'S (NPM) APPOINTMENT OF REGISTERED AGENT FOR THE STATE OF GEORGIA AND REGISTERED AGENT'S STATEMENT Please print or type in permanent dark ink - Sign, date, and return original to: Office of the Attorney General for the State of Georgia Georgia Department of Law Consumer Interest Section 40 Capitol Square, SW Atlanta, GA 30334 NON-PARTICIPATING TOBACCO MANUFACTURERS: The undersigned Non-Participating Manufacturer ("NPM") _________________________ hereby appoints and authorizes __________________________________________________ as its registered agent to receive service of process on our behalf. The undersigned NPM agrees to provide notice to the Office of the Attorney General for the State of Georgia ("Attorney General"), at least 30 calendar days prior to termination of the authority of the registered agent, and to 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 an existing agent appointment. Under penalty of perjury, I certify and declare that all of the statements and information contained in this Certification, including but not limited to any accompanying statements or attachments herewith, are true, accurate and complete in every particular and that I am a person authorized to bind the NPM making the Certification either under the laws of the State of Georgia or of the jurisdiction where the manufacturer resides or is organized. Any violation of the requirements of O.C.G.A. 10-13A-6 is a basis for removal of the applicant's Brand Families from the list of compliant NPMs. ** This Certification must be signed and dated by an authorized notary public. ** Under penalty of perjury, I state that the information contained in this document is true and accurate. Signature of Designee for Non-Participating Manufacturer: _______________________ Designee (Print Name): _____________________________________________________ Title: ____________________________________________________________________ Principal Place of Business (physical address): ________________________________ _________________________________________________________________________ STATE OF ______________________________} COUNTRY OF ___________________________} Subscribed and sworn to before me on this date: Signature of Notary Public: _____________________ My Commission expires: _______________________ Form AG02 Page 1 of 2 1/1/05 American LegalNet, Inc. www.FormsWorkflow.com City or County of ____________ NAME AND ADDRESS OF GEORGIA STATE REGISTERED AGENT: Name: ___________________________________________________________________ Street Address (Required Must be within Georgia): _______________________________ P.O. Box: _________________________________________________________________ City & State: _____________________________ Zip Code: ________________________________ Telephone: _______________________________ Fax: ____________________________________ Email Address:____________________________ I consent to serve as Registered Agent in the State of Georgia for ______________________, the above-named NPM, pursuant to O.C.G.A. 10-13A-6. 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 Certification must be signed and dated by an authorized notary public. ** Signature:_____________________________________ Date: _____________________ County: _________________________ Print Name: _______________________________________________________________ Title: _____________________________________________________________________ STATE OF _______________________________ } COUNTRY OF ___________________________ } Subscribed and sworn to before me on this date: ______________________ Signature:_____________________________________________________ My Commission expires: _________________________________________ Form AG02 Page 2 of 2 1/1/05 American LegalNet, Inc. www.FormsWorkflow.com
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