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Non-Participating Manufacturers Appointment Of Registered Agent - Oregon
| Non-Participating Manufacturers Appointment Of Registered Agent 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'S (NPM) APPOINTMENT OF REGISTERED AGENT FOR STATE OF OREGON 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 Oregon Oregon Department of Justice Civil Enforcement Division; Attn: Tobacco Enforcement 1162 Court Street, NE Salem, OR 97301-4096 NON-PARTICIPATING TOBACCO MANUFACTURERS: The undersigned Non-Participating Manufacturer ("NPM") __________________________________ hereby appoints________________________________________________________________________ as its registered agent to receive service of process on our behalf; said registered agent is authorized to receive service of process on behalf of the NPM. The undersigned NPM also agrees to do the following: (1) provide notice to the Office of the Attorney General for the State of Oregon ("Attorney General"), at least 30 calendar days prior to termination of the authority of the registered agent; and (2) 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. The undersigned NPM further agrees that if the agent terminates its agency appointment, the undersigned shall provide notice to the Attorney General of the termination within five calendar days with proof to the Attorney General of the appointment of a new agent and a new Non-Participating Manufacturer's (NPM) Appointment of Registered Agent for State of Oregon and Registered Agent's Statement form. 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, correct, accurate and complete in every particular and that I am a person authorized to bind the NPM making this Certification either under the laws of the State of Oregon or of the jurisdiction where the manufacturer resides or is organized and I have attached an authentic, certified copy of document(s) as proof of my authority to bind the NPM. Any violation of the requirements of ORS 323.800 to 323.806 or ORS 180.400 to 180.455 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.** Signature of Designee for Non-Participating Manufacturer: ____________________________________ Designee (Print Name):__________________________________________________________________ Title: _________________________________________________________________________________ Principal Place of Business (physical address):______________________________________________ STATE OF COUNTY OF COUNTRY OF ) ) ) On________________________________before me,__________________________, personally appeared ___________________________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature _________________________________________________ My Commission expires: _______________________ Non-Participating Manufacturer Certification Statement of Registered Agent Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com NAME AND ADDRESS OF OREGON STATE REGISTERED AGENT: Name: ______________________________________________________________________________________ Street Address (Required Must be within Oregon): ____________________________________________ PO Box (Optional Must be in same city as street address): ______________________________________ City & State: _______________________________________________ Zip Code: ________________ Telephone _________________________________________ I consent to serve as Registered Agent in the State of Oregon for the above named NPM, pursuant to ORS 323.800 to 323.806 or ORS 180.400 to 180.455. 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: _____________________ Print Name: ___________________________________________________________ Title: ________________________________________________________________ STATE OF COUNTY OF COUNTRY OF ) ) ) On________________________________before me,__________________________, personally appeared ___________________________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature _________________________________________________ My Commission expires: _______________________ CEDF0412/32206 Non-Participating Manufacturer Certification Statement of Registered Agent Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com
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