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Non-Participating Manufacturer Certification Form - Wyoming
| Non-Participating Manufacturer Certification Form Form. This is a Wyoming form and can be used in Tobacco Settlement Unit Office Of The Attorney General Statewide . |
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State of Wyoming Tobacco Product Manufacturer Certification For Listing on the Wyoming Directory Pursuant to Wyoming Statutes §§ 9-4-1201 through 1202; and 9-4-1205 through 1210 Sales Year 2012 (Due on or Before April 30, 2013) (Effective October 1, 2012, Certifications for New Manufacturers will only be considered between March 1st and April 30th of each year.) I. INTRODUCTORY INFORMATION Please provide the following information for brands being certified in the State of Wyoming. Attach additional sheets, as needed, to provide complete responses. Failure to fully complete the Certification and provide all requested documentation may result in delay or denial of certification. II. APPLICANT INFORMATION A. Applicant is: A Participating Manufacturer under the Master Settlement Agreement (MSA). A Nonparticipating Manufacturer as defined in W.S. § 9-4-1210(a)(vi). B. Name of Applicant: C. Contact Person: D. Physical Address: E. Mailing Address: F. Website Address(es): G. Telephone Number: H. Facsimile Number: I. E-mail Address: J. Name/Title of Person(s) Completing form: K. If Applicant is represented by counsel, and if applicant gives its authorization for the Wyoming Attorney General's office to contact counsel on matters related to this certification, please provide counsel's name and contact information. American LegalNet, Inc. www.FormsWorkFlow.com L. Please attach the Applicant's organizational documents. Check here if you have already provided the organizational documents. It is not necessary to provide organizational documents that have already been provided to the Wyoming Attorney General's office. Name: Title: Equity Interest: Address: Telephone #: E-mail Address: N. If located in the U.S., Applicant Manufacturer's Federal Taxpayer ID: O. Has the Applicant, directly or through a retailer, distributor or similar intermediary, participated in the direct sale of its Cigarettes to customers via catalog, the Internet, by phone or by mail? Such participation includes the sale of Applicant's Cigarettes to a retailer that in turn sells directly to customers via catalog, the Internet, by phone to by mail. Please select Applicant's response from those presented below or provide an explanation as to why none apply. The Applicant directly sells its Cigarettes to customers via catalog, the Internet, by phone and/or by mail. If Applicant sells its products via the Internet, please provide the website address for the site(s) at which its products are sold. The Applicant provides its Cigarettes to retailers and/or distributors which sell directly to customers via catalog, the Internet, by phone and/or by mail. If so, please provide the name, website address, physical mailing address, and telephone number for all such retailers. The Applicant does not participate, directly or through a retailer, distributor or similar intermediary, in the direct sale of its Cigarettes to customers via catalog, the Internet, by phone and/or by mail. III. CIGARETTE REQUIREMENTS A. Please check here if the Applicant is only certifying RYO tobacco brands and go to question III.(E). The Applicant is certifying RYO tobacco brands only B. FIRE SAFE - Provide a copy of the current certification from the Wyoming State Fire Marshal's office for each brand being certified as required by the Wyoming Reduced Cigarette Ignition Propensity Act. Attached as Exhibit ___. Note that FSC certification from the Wyoming State Fire Marshal's office must be obtained prior to requesting that a cigarette brand be listed in the Directory. C. INGREDIENT LIST - Provide a copy of the current Centers for Disease Control "Certificate of Compliance" or similar letter approving the ingredient list for cigarettes for the brand families sold in the State of Wyoming. Attached as Exhibit ___. American LegalNet, Inc. www.FormsWorkFlow.com D. ROTATION PLAN - Provide a copy of the current Federal Trade Commission letter authorizing the health warning rotation plan for the brand families sold in the State of Wyoming. E. JENKINS/PACT ACT - For each of the past 12 calendar months, has the Applicant provided the reports required by 15 U.S.C. § 375 et seq. to the Wyoming Department of Revenue? Yes No F. TTB NUMBER - List Applicant's U.S. Treasury, Tobacco Tax Bureau Permit Number as a manufacturer and as an importer: Manufacturer: Importer: IV. BRANDS AND STYLES A. BRANDS AND STYLES Currently Certified Manufacturers - Enclosed is a copy of the current brand listing for the Applicant. Put a check mark beside each brand and style that is being certified in the State of Wyoming for the current year. Identify with an asterisk any brand or style sold in the state during the preceding year that is no longer being sold in the state as of the date of certification. Return the brand listing with this certification. (For those brands or styles no longer being sold in the State of Wyoming, please advise your distributor that the brand or style will be considered contraband immediately upon removal from the Directory.) New Nonparticipating Manufacturers - List below all brands, including styles and varieties, being certified for sale and inclusion in the State of Wyoming's June 1, 2013 release of the directory. Brand Style B. PACKAGING - Please provide a DVD with color photographs of packaging for each brand style being certified showing all printed sides of each package. Applicants are under an on-going obligation to supplement this application with sample packaging when any material change is made to brand style packaging. V. TRADEMARK HOLDER Is the Applicant the trademark holder of all brands being certified for listing in the State of Wyoming? Yes No If not, for those trademarks not held by the Applicant, identify the trademark holder for each listed brand(s) below, provide an explanation for the inclusion of the brand(s) in this certification, and provide a copy of any agreement for use of the trademark by the Applicant. Brand Trademark Holder Physical Address Phone Number IF THE APPLICANT IS A PARTICIPATING MANUFACTURER, SKIP SECTION VI AND GO TO SECTION VII (SIGNATURE AND DATE) American LegalNet, Inc. www.FormsWorkFlow.com VI. FOR NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURERS ONLY A. Does Applicant actually physically fabricate all brand styles for which certification is sought? Yes No If not, which brand styles does Applicant actually fabricate? B. Manufacturing Plant(s) Name and Address: (i) Name of Plant: (ii) Brand(s) made at Plant: (iii) Physica
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