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Non-Participating Manufacturer Certification Of Additional Information NPM-AI - New Jersey
| Non-Participating Manufacturer Certification Of Additional Information Form. This is a New Jersey form and can be used in Tobacco Enforcement Office Of The Attorney General Statewide . |
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State of New Jersey Non-Participating Manufacturer Certification of Additional Information NPM-AI Part 1: Certification Year and Type of Certification Certification Year: Complete a separate form for each Certification year that you are certifying. Certification year 2013 is for sales made in 2012. (check one) 2013 Annual Other: ______ Supplemental Type of Certification: (check one) Initial Part 2: M anufacturer Identification Company Name Name and Title of Person Completing this Form Mailing Address City Phone Part 3: NPM Status References to cigarettes (includes roll-your-own tobacco) are to the brand families certified on the NPM-AI form submitted by the manufacturer identified in Part 2. 9 9 Yes 9 9 No NPM is the fabricator of the brand families listed on the NPM-AI form and intends for the cigarettes to be sold in the U.S., including cigarettes intended to be sold in the U.S. through an importer. NPM is the first purchaser anywhere for resale in the U.S. of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the U.S. State Fax Zip Code FEIN Country Yes No Part 4: Additional Information Requested by Attorney General's Office A. All NPMs must provide the information requested in this section. Provide a response to each question. All attachments must indicate the question to which it corresponds. 1. A listing of all company officers and owners (all persons with an equity interest of 10% or more in company). A complete list of cigarettes (including roll-your-own tobacco "RYO") that NPM, its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and place of manufacture for those brands. List the cigarettes and RYO by brand name and brand family. 2. 3. A complete list of tobacco products (e.g. cigars, pipe tobacco, smokeless tobacco, etc.) that NPM and its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and the place of manufacture for those brands. Provide names, addresses, telephone numbers, and, if available, email addresses of all tax stamping agents (licensed or not) the NPM sells cigarettes to (including RYO) located in New Jersey or another State. Provide names, addresses, telephone numbers and, if available, email addresses of all the retailers, importers, distributors, wholesalers or similar intermediaries the NPM sells cigarettes to (including RYO) located in New Jersey or another State. Provide a list of States that have certified the NPM and the brand families certified in those States. If any State has refused to list or removed NPM from a State's directory, identify the State(s). List all internet websites where NPM cigarettes or tobacco products are sold, even if without NPMs express authorization. Provide the name, address and telephone number of owner of the domain name of the website. Provide a separate listing for each brand of cigarettes or tobacco products if necessary. American LegalNet, Inc. www.FormsWorkFlow.com 4. 5. 6. 7. State of New Jersey Non-Participating Manufacturer Certification of Additional Information NPM-AI Part 4 (continued) 8. If NPM intends to sell or authorizes any other entity to sell any cigarettes or roll-your-own into New Jersey by mail order or through the internet, provide the internet website and/or identify publications. Attach a letter addressed to the Attorney General's office stating you sent reports or invoices to the New Jersey Division of Taxation to comply with the Jenkins Act (Chapter 10A of Title 15 of the U.S. Code, Section 375 et seq.), as amended by the Prevent All Cigarette Trafficking (PACT) Act, for sales in the last 12 months. Attach copies of any agreements authorizing another to sell your brand families by mail order or through the internet. B. NPMs located in foreign countries must provide the information requested in this section. Provide a response to each question or indicate N/A. All attachments must indicate the question to which it corresponds. 1. Copy of the license, permit or other registration documents required by the country where the brand families certified in Part 3 of NPM-AI are manufactured. Name, address, phone number, and email address for all importers for the brand families certified in Part 3 of the NPM-AI certification form. 2. Part 5: M anufacturer Certification Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this Certification and any attached documents are true and accurate and that I am a person authorized to bind the manufacturer making this certification either under the laws of the State of New Jersey or of the jurisdiction where the manufacturer resides or is organized. I understand that the Attorney General may require additional information and/or documentation to determine whether the manufacturer qualifies for listing on the New Jersey Directory. This document must be signed and dated by an authorized notary public. NPM Authorized Designee (Print Name) Title Signature of NPM Authorized Designee Date Subscribed and sworn to before me this date: Signature of Notary Public County Commission Expires Rev. 2/20/2013 American LegalNet, Inc. www.FormsWorkFlow.com
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