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Certificate Of Compliance - South Carolina
| Certificate Of Compliance Form. This is a South Carolina form and can be used in Tobacco Unit Office Of Attorney General Statewide . |
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STAT OF SOU TE UTH CARO OLINA TOBACCO PRODUC MANUF O CT FACTURER R CERTI IFICATE O COMPL OF LIANCE [Pursuant to S.C. Code A [ Ann. §§11-4 47-10 to -30, and §§11-4 , 48-10 to -110 0] 13 ARTICIPAT TING MAN NUFACTUR RER 201 NON-PA CE ERTIFICA ATION FOR RM IMP PORTANT NOT TICES FIL LING DEADLIN is April 30, 2013. Certification Forms must be postmarked n later than Ap 30, 2013 to a NE 2 no pril avoid rem moval from the South Carolina To obacco Directory. . ease Type or Prin The Attorney General's Office will not process incomplete or ille nt. i egible Certificatio Forms. on Ple his upplemented to reflect any change in informatio at any time d on during the year. Any Th Certification Form must be su cha ange of informati must be subm ion mitted 30 days prior to change. Th failure to notify the Attorney G he fy General's Office of any cha anges to this information 30 days prior to any chan including cha nge, anges in address, may result in rem , moval from the S South Ca arolina Tobacco Directory. D Ple ease refer any questions to the Off of the Attorne General Tobac Unit at (803) 7 fice ey cco 734-3704. Mail this completed Certificat of Compliance and te a attachmen to: nts South Ca arolina Office of the t Attorney General y Tobacco Unit P.O. Box 11549 x Columbi SC 29211 ia, PA ART 1: TOB BACCO PRO ODUCT MA ANUFACTUR RER IDENT TIFICATION N T Type of Certi ification (che one): eck Initial Cer rtification Applicant not currently listed on the Sou Carolina T A uth Tobacco Dire ectory Annual Certification Due April 30 2013 0, Suppleme ental Certifica ation Chang of informat ge tion provided to the Attorn General o request to a d ney or add Additiona brands to th South Caro al he olina Tobacco Directory o C Company Inf formation: A Applicant Com mpany Name: M Mailing Address: C City: State: P Phone: Fax: F N Name of Person Completin Certificatio ng on: N Name of Cont Person if Different fro Above: tact f om M Manufacturing Facility In nformation: P Plant Name: P Physical Addr ress: C City: State: P Phone: Fax: F N Name of Factory Manager( (s): Zip: E Email: Cou untry Zip: E Email: Cou untry: Page 1 of 7 P American LegalNet, Inc. www.FormsWorkFlow.com L Licenses and Permits: I located in U.S. Manufa If U acturer's Fede Taxpayer ID Number: eral r : I located in U.S. TTB Pe If U ermit Number r: Expires s: P Please indicat if TTB Perm was obtai te mit ined as a man nufacturer or i importer: F Foreign Manu ufacturer Perm or License Issued: mit e Expires s: C Copy of Abov Applicable Permit Attac ve e ched YES S NO A Attorney Info ormation: A Attorney Nam me: F Firm Name: F Firm Mailing Address: C City: P Phone: State: Fax: F Zip: E Email: Cou untry: T Tobacco Prod duct Manufa acturer Addi itional Inform mation: 1. Appl licant is the manufacturer (i.e. fabricator of the bran listed in th certificatio which are intended m ( r) nds his on, to be sold in the Un nited States, including ciga i arettes intend to be sold in the United States throu an ded d d ugh impor rter. YES N NO 2. If the answer is "Y e YES," please attach a photo ograph or dia agram of your manufacturi facility an r ing nd indica on the pho ate otograph or di iagram where the equipme and facilit for manuf e ent ties facturing (i.e. fabric cating) the cig garettes, if any are located y, d. 3. Appli icant is the fir purchaser anywhere for resale in the United States of cigarettes manufactured rst a r d anywh that the manufacturer does not inte to be sold in the United States here m r end d YES N NO 4. If the answer is "Y YES," identify each cigarette manufactu (i.e. fabric y urer cator), its plan address, m nt mailing address, contact pe erson, phone, and fax numb bers, and the relationship t Applicant. Identify the location to of the transfer of ownership of cigarettes and a copy of ev e c d very agreemen or contract between App nt t plicant and fa abricator. Att tach additiona sheets as ne al ecessary to pr rovide a comp plete respons se. 5. Appli icant is succes of an ent described in questions 1 or 3 above (i.e. manufac ssor tity cturer or first impor rter). Please identify the predecessor(s) i p ). YES N NO 6. If Ap pplicant answered "NO" to questions 1, 3, or 5 above explain the basis for the Applicant's c o e, claim that it is a Tobacco Pro oduct Manufac cturer (TPM) as defined un ) nder South C Carolina Code Ann. §§11-4 47-10 to 110. Please submi all documen it ntation to sup pport Applican contentio Attach ad nt's on. dditional sheets as necessary to provid a complete response. de e O Organization Documen nal nts: Check One: k Attach the following do ocuments or in nformation: R Response P Provided Does Not Apply Partnership or Associati p ion: Current copy of the C Certificate of Partnership o the or certificate required to be filed by any state, county or municip y y, pality. Corporatio 1.Current copy of the C on: t Certificate of Incorporation or other cha f n arter and 2. Extracts of document listing the o s ts officers autho orized to sign for the comp pany. LLC or oth entity: Cu her urrent copy o f the business document(s) filed with a state, s county, or municipality when such fi iling is requir red. Include a copy of any y rsons authori zed to sign fo the entity. or document indicating per Page 2 of 7 P American LegalNet, Inc. www.FormsWorkFlow.com Company Officers/Own O ners: Provide a list of all c e company offic and comp cers pany owners (all persons with an equity in h nterest of 10% or more in t company) Include % the ). name, addr ress, phone nu umber, and em address. mail . Affiliates: Provide a lis of all comp st pany affiliates pursuant to S Code An §11s S.C. nn. 47-20(b) th also manu hat ufactures, imp ports, distribu utes, or sells c cigarettes or R RYO. Include the name, addre and conta informatio for each af e ess, act on ffiliate. Marketing Information: For each bra family, li the name, address, and contact and ist information for each dis stributor and w wholesaler th hrough which the applicant intends h t to sell ciga arettes or RYO in South Ca O arolina. Agreement with Partic ts cipating Manu ufacturers: Id dentify every agreement be etween Applicant and any Parti icipating Man nufacturer (PM or PM Aff M) filiate that rel lates to the making importing, distribution, t g, transportation or sale of e n, each brand fam mily. Agreement Regarding Compliance w the Qualified Escrow Statute: Lis every ts with w st brand fami that is the subject of an agreement regarding com ily ny mpliance with
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