Oklahoma > Statewide > Attorney General > Tobacco Enforcement Unit
Tobacco Product Manufacturer Certificate For Listing On Oklahoma Directory - Oklahoma
| Tobacco Product Manufacturer Certificate For Listing On Oklahoma Directory Form. This is a Oklahoma form and can be used in Tobacco Enforcement Unit Attorney General Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
STATE OF OKLAHOMA TOBACCO PRODUCT MANUFACTURER CERTIFICATION FOR LISTING ON OKLAHOMA DIRECTORY (68 O.S. §§ 360.1, et seq.) Mail this completed certification and all attachments to: Office of the Attorney General State of Oklahoma Tobacco Enforcement Unit 313 NE 21st Street Oklahoma City, OK 73105 G 1. Initial G Supplemental G Renewal Sales Year: 2012 PART I: GENERAL BUSINESS AND OWNERSHIP INFORMATION Applicant Tobacco Product Manufacturer Identification Applicant: Physical Address of Manufacturing Plant: Mailing Address: Phone Number: E-Mail Address: Name/Title of Person Completing Certification: 2. The undersigned certifies that as of the date of this Certification, the above-named applicant is: (Please Initial One) Facsimile Number: G a Participating Manufacturer ("PM") and has generally performed its financial obligations under the Master Settlement Agreement. (See Instructions) G a Nonparticipating Tobacco Product Manufacturer ("NPM") in full compliance with 37 O.S. §§ 600.21600.23, having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales, including any quarterly deposits the applicant was notified it was required to make. a. If the Applicant Was Notified by Any State That it Was Required to Place Funds into Escrow and the Applicant Did Not Timely Do So And/or Was De-Listed by Any State, Provide a Full Explanation for Each Failure to Timely Deposit. Attach additional sheet(s), as necessary, to provide a complete response b. 3. Is Applicant Located Outside the United States? G Yes G No Applicant is the actual manufacturer (i.e., fabricator) of the brands listed in this Certification which are intended to be sold in the United States, including Cigarettes intended to be sold in the United States through an importer. G Yes G No If Your Answer Is "No", Identify the Name and Address of the Fabricator and State Fully the Applicant's Basis for Seeking to Have the Brand(s) Included in the Directory. Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Attach additional sheet(s), as necessary, to provide a complete response. 4. A Company Other than Applicant Manufactured Any of Applicant's Cigarettes During Any Time in the Previous Year. G Yes G No If the answer is "Yes", identify each Cigarette manufacturer (ie, fabricator), its plant street address, mailing address, contact person, telephone and facsimile phone numbers, and the relationship to applicant, if any. Provide a copy of every agreement or contract between applicant and the fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 5. Applicant is the first purchaser for resale in the United States of Cigarettes manufactured anywhere. G Yes G No If the answer is "Yes" , identify each Cigarette manufacturer (ie, fabricator), its plant street address, mailing address, contact person, telephone and facsimile phone numbers, and the relationship to applicant. Identify the location of the transfer of ownership of Cigarettes and a copy of every agreement or contract between applicant and fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 6. INDIAN TRIBE/NATION AFFILIATION A. B. C. Is Applicant a Federally Recognized Indian Tribe/Nation or a Legal Entity Formed under Tribal Law? Is Applicant Owned by a Member(s) of an Indian Tribe/Nation and Located On Tribal Land? Does Applicant Have or Make Any Claim of Tribal Sovereign Immunity? G Yes G No G Yes G No G Yes G No If Your Answer to Any of These Questions Is "Yes", Please Provide the Information Requested below and Contact the Oklahoma Office of the Attorney General, Tobacco Enforcement, to Make Arrangements to Execute Required Waivers of Sovereign Immunity in Order to Appear on the Oklahoma Tobacco Product Manufacturers Directory. (See Instructions) Full Name of Tribe Mailing Address of Tribal Headquarters Telephone Number for Tribal Headquarters 7. Licenses/Permits: a. Attach copies of all current and valid licenses from the Oklahoma Tax Commission (OTC). b. U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number as a Manufacturer: and/or as an importer: . Attach a copy of Applicant's current permit as a manufacturer or importer pursuant to 26 USC Chapter 52, and regulations issued thereunder. c. Federal Taxpayer ID Number: . Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com d. If applicant is a manufacturer located in a country other than the U.S.A., provide copies of any Tobacco Manufacturer's License/Certificate/Permit or similar document(s), or an Importer's License/Certificate/Permit or similar document(s) issued by the country where the manufacturing takes place. PART II: BRAND FAMILY IDENTIFICATION 8. Brand Family Identification B. Units Sold in Preceding Calendar Year C. Manufacturer of Brands Listed Include complete address information A. Brand Family Indicate those brands that will not be sold in 2012 with an asterisk (*) Attach additional sheet(s), as necessary, to provide a complete response. If not previously submitted, or if the previously submitted packaging has changed, attach samples of the actual packaging and labeling for each brand of Cigarettes that applicant intends to sell in Oklahoma. Also submit on CD or DVD, a color photograph in PDF format, of the packing and labeling. See Instructions. 9. PACKAGING SAMPLES (check one) G G Initial or Supplemental Application: Samples of the actual packaging and labeling for each brand (without tobacco) are attached. Renewal Application: Samples of packaging for all brands and products sought to be certified in the current year have been previously provided and there has been no changes in the packaging. 10. Trademark Holder(s) Provide the name, address, and phone number of the trademark holder(s) of each brand listed above. Brand Trademark Holder and Contact Person Physical Address Phone Attach additional sheet(s), as necessary, to provide a complete response If the Trademark Holder of a Listed Brand Is Not the Applicant, Provide a Complete Explanation for the Inclusion of the Brand(s) in this Application, a Copy of Any Agreement(s) for the Use of the Trademark by the Applicant, and a Sworn Affidavit from the Trademark Holder Confirming That No Entity Other than Applicant Is Authorized to Manufacturer the Brand Family(s) for Which Certification Is Requested. PART III: BUSINESS ORGANIZATIONAL INFORMATION 11. Organizational Documents to Be Attached (See Instructions for list of documents required
|
|||||||
