North Carolina > Statewide > Department Of Justice > Attorney Generals Office > Consumer Protection Division
Non-Participating Manufacturers Application Annual Certification - North Carolina
| Non-Participating Manufacturers Application Annual Certification Form. This is a North Carolina form and can be used in Consumer Protection Division Attorney Generals Office Department Of Justice Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
2012 NORTH CAROLINA NON-PARTICIPATING MANUFACTURER'S APPLICATION / ANNUAL CERTIFICATION [Pursuant to N.C. Gen. Stat § 66-291 and § 66-294] Date: _______________ Please check the appropriate box: G G G Initial Certification --Tobacco Product Manufacturer/Applicant is not currently listed on the North Carolina Approved Tobacco Directory. Annual Certification -- NPMs must file by April 30, 2012 for all brands sold in North Carolina. Supplemental Certification Change of information provided to the Attorney General, or to request addition or deletion of brands to the North Carolina Tobacco Directory. Sales year for which you are certifying compliance: 2011 NOTE: ESCROW DEPOSIT DUE APRIL 16, 2012 **NEW FOR 2012 CERTIFICATION: If you are an importer or trademark owner on the multiple entity escrow agreement, you are required to fill out the information requested herein. PART 1: Tobacco Product Manufacturer (TPM) Identification North Carolina requires the entity or entities that control or own the manufacturing process and that control the Brand mark to apply and be responsible for Brand(s) approved for sale and for the escrow payments. Per N.C. Gen. Stat. § 66-291(b) escrow may only be released for three reasons: (1) to pay a judgment or settlement against a manufacturer; (2) to return funds to manufacturer in excess of State's escrow requirement under N.C. Gen. Stat. § 66-291(b)(2); or (3) if not released under 1 or 2, to be returned to a TPM 25 years after the date the TPM places the funds in escrow. **Please complete every section for each entity making application/certification for a Brand. A. Company Name: Street Address: City: Telephone Number: Company contact email address: PO Box: State: Fax No: Zip Code Revised (03/12) American LegalNet, Inc. www.FormsWorkFlow.com Name of Person Completing Application/Certification: Email Address: _ ______________________________________ ATF (TTB) Tobacco Permit Number: ______________________ N.C. Distributor's License Number: _______________ (N. C. Gen. Stat. §§105.113.4(3)(b); 105.113.11) (If applicable - see Part 3, Section B) Identify the form of business entity: G Corporation G General Partnership G Limited Partnership G G G (explain) Limited Liability Company Sole Proprietorship Other The entity identified above is as of the date of this application/certification: (Check all applicable boxes) G Trademark Owner of Brand Mark G Fabricator of Tobacco Product G First Importer for resale in the United States G Other (please explain relationship) _____________________________ If represented by an Attorney, provide the following information: Attorney's Name:_ Firm Name: _ Firm Mailing Address: Telephone Number: ________________________Fax Number: Email Address: States where licensed: **Importer/Trademark Owner Complete Section Below. B. Company Name: Street Address: ________________________________; P.O. Box City _______________________, State ______________; Zip Code Telephone Number _________________, Fax Number: Company Contact email address: Name of Person Completing Application/Certification: Email Address: _______________________________________ ATF (TTB) Tobacco Permit Number: ______________________ N.C. Distributor's License Number: _______________ (N. C. Gen. Stat. §§105.113.4(3)(b); 105.113.11) (If applicable - see Part 3, Section B) Identify the form of business entity: G Corporation G General Partnership G Limited Partnership G Limited Liability Company G Sole Proprietorship G Other __________________ (explain) Revised (03/12) -2- American LegalNet, Inc. www.FormsWorkFlow.com The entity identified above is as of the date of this application/certification: (Check all applicable boxes) G Trademark Owner of Brand Mark G Fabricator of Tobacco Product G First Importer for resale in the United States G Other (please explain relationship) _________________________ If represented by an Attorney, provide the following information: Attorney's Name:_____________________________________________ Firm Name: _________________________________________________ Firm Mailing Address: Telephone Number: ___________________ Fax Number Email Address: States where licensed: PART 2: Required Documentation - Attach a plain sheet of paper to the front of each document that identifies the document by item letter and name. **Please complete every section for each entity making application/certification for Brand. G A. Service of Process Information: N.C. Gen. Stat. § 66-294(b)(1) states an NPM must appoint and continuously maintain a process service agent within North Carolina to accept service of any notification or enforcement of an action under this Article. The manufacturer/applicant shall file a certified copy of each instrument appointing a process service agent with the Secretary of State and the Office of the Attorney General, and provide a current letter from the registered agent accepting this appointment. G G **A.(1) Service of Process Information: Importer/Trademark Owner for Multiple Entity Escrow Only. B. Authority to Sign: If applicant is an entity other than an individual, including without limitation, all partnerships and/or corporations, the applicant must provide information showing that the person who signs has the authority to sign and make binding commitments for the applicant. Examples of such documents include, Partnership Agreements, Articles of Incorporation and Board Resolutions showing the names of the persons authorized to sign on behalf of the applicant. G **B.(1) Authority to Sign: Importer/Trademark Owner for Multiple Entity Escrow Only. Revised (03/12) -3- American LegalNet, Inc. www.FormsWorkFlow.com G C. Escrow Agreement: Provide copy of your current executed Escrow Agreement. PLEASE NOTE that your company's Escrow Agreement must conform to North Carolina's Model Escrow Agreement and any deviation in language will not be accepted. North Carolina's Model Escrow Agreements, single and multi-entity, can be found at www.ncdoj.com. G G **C.(1) Escrow Agreement: Importer/Trademark Owner for Multiple Entity Escrow Only. D. CDC Letter: A letter from the U.S. Center for Disease Control showing a current approval of the ingredient list for the above referenced cigarette Brand. (N.C. Gen. Stat. § 14-401.18) G E. U.S. Federal Trade Commission: A letter from the U.S. Federal Trade Commission showing current approval of the warning label plan for the above referenced cigarette Brand. (N. C. Gen. Stat. § 14-401.18) G F. Proof of Tradema
|
|||||||
