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Non-Participating Manufacturer Certification - Oregon
| Non-Participating Manufacturer Certification Form. This is a Oregon form and can be used in Civil Enforcement Division Office Of Attorney General Statewide . |
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NON-PARTICIPATING MANUFACTURER CERTIFICATION FOR LISTING ON OREGON DIRECTORY CURRENT DATE: _____________ Initial Certification Annual Certification Supplemental Certification **** ALL INFORMATION MUST BE COMPLETED IN FULL OR APPLICANT WILL BE DENIED LISTING ON THE OREGON DIRECTORY**** Mark "NA" if a question is not applicable. Attach additional sheets where necessary to provide a complete response. Part 1: Manufacturer Identification Applicant Name: _____________________________________________________________________________ Mailing Address: _____________________________________________________________________________ ___________________________________________________________________________________________ Physical Address: _____________________________________________________________________________ ___________________________________________________________________________________________ Phone: ____________________________________ FAX:____________________________________________ E-Mail Address: ______________________________________________________________________________ Website Address: _____________________________________________________________________________ Name/Title of Person Completing Certification: _____________________________________________________ Plant Name and Physical Address: ________________________________________________________________ Plant Phone:________________________________ FAX:_____________________________________________ Name/Title of Person at Plant if different from above: ________________________________________________ Part 2: Status as Tobacco Product Manufacturer The undersigned certifies that as of the date of this Certification, the above-named Applicant is a NonParticipating Tobacco Product Manufacturer in full compliance with ORS 323.800 to 323.806, including having made all required payments into a Qualified Escrow Fund as defined in ORS 323.800(6). The Applicant qualifies as a Non-Participating Tobacco Product Manufacturer because (check all that apply): The Applicant is the fabricator of the listed brands in this Certification which are intended to be sold in the United States including Cigarettes and RYO intended to be sold in the United States through an importer. The Applicant is the first purchaser anywhere for resale in the United States of Cigarettes and RYO manufactured anywhere that the manufacturer does not intend to be sold in the United States. If yes, provide the name, address, plant address, contact person, phone and fax number of the fabricator. The Applicant is a successor of any entity described above (i.e., manufacturer/first importer). NON-PARTICIPATING MANUFACTURER CERTIFICATION CEDW3168 PAGE 1 of 8 American LegalNet, Inc. www.FormsWorkflow.com Part 3: Brand Family and Brand Style Identification A. Brand Family and Styles. Complete the following table. Attach additional sheets if necessary. Brand (Indicate with an asterisk (*) those brands that will not be sold in the current year) Go to Heaven (Example) Brand Style Please list in order below. [Flavor, Size, Container, Type] C = Cig R = RYO RIP Certified and approved by the Oregon State Fire Marshal Yes / No Yes Units Sold in Oregon in Preceding Calendar Year (i.e., Sales Year) 12,345 Units Sold in Oregon in Current Calendar Year (i.e., January through April of year filing) 100 Previous Manufacturer (include address) Current Manufacturer (include address) Trademark Holder (include address) Menthol 100 Box C Go to Heaven (Example) Light King Soft C No 13,455 200 Pearlley Gates Tobacco Company 457 Limit Road Salem, OR 97301 Pearlley Gates Tobacco Company 457 Limit Road Salem, OR 97301 Pearlley Gates Tobacco Company 457 Limit Road Salem, OR 97301 Pearlley Gates Tobacco Company 457 Limit Road Salem, OR 97301 Luther Cross 765 Main Street Salem, OR 97301 Luther Cross 765 Main Street Salem, OR 97301 B. Packaging Samples: Check the appropriate box(es): Initial or Supplemental Certification: Corresponding actual cigarette or RYO packaging (without tobacco) of all Brands and Brand Styles identified above is included. Annual Certification No Packaging Changes: Corresponding actual cigarette or RYO packaging (without tobacco) of all Brands and Brand Styles identified above has been previously provided and there have been no changes in the packaging. Annual Certification Packaging Changes/Brand Additions: There have been changes to packaging samples previously submitted or new brand styles have been added and corresponding actual cigarette or RYO packaging (without tobacco) is included. RIP (Reduced Ignition Propensity): Letter attached from Oregon State Fire Marshal along with certification testing verification for cigarettes to be certified. C. Brand Responsibility: The Non-Participating Manufacturer identified in Part 1 affirms that the cigarette and RYO brands listed in Part 3A above are to be considered the Non-Participating Manufacturer's cigarette and RYO brands for purposes of ORS 323.800 to 323.806. ____________ (Initial here). NON-PARTICIPATING MANUFACTURER CERTIFICATION PAGE 2 of 8 CEDW3168 American LegalNet, Inc. www.FormsWorkflow.com Part 4: Licenses and Permits U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number as a manufacturer: _______________ and/or as an importer: _____________________________. Manufacturer's Permit or License Number: _________________________________________________ Name Permit or License is Listed Under: ___________________________________________________ Country Permit or License Issued: ________________________________________________________ Last Year Permit or License Issued: _____________________ Is Permit or License Current?_________ Check One: Initial Certification or Changed Permit: A copy of applicant's current permit as a manufacturer or importer pursuant to 26 USC Chapter 52 is attached. Annual or Supplemental Certification: A copy of applicant's current permit as a manufacturer or importer pursuant to 26 USC Chapter 52 was previously submitted and there have been no changes to the permit. Part 5: Additional Business Information A. Organizational Documents: Attach organizational documents as follows: i. Initial Certification: Check appropriate box: For a partnership or association: Current copy of the Certificate of Partnership or the certificate required to be filed by any state, county or municipality. For a corporation: 1) Current copy of the Certificate of Incorporation or other charter and 2) Extracts of docum
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