Pennsylvania > Statewide > Office Of Attorney General > Tobacco Enforcement Section
Non-Participating Manufacturer Certification Form - Pennsylvania
| Non-Participating Manufacturer Certification Form Form. This is a Pennsylvania form and can be used in Tobacco Enforcement Section Office Of Attorney General Statewide . |
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COMMONWEALTH OF PENNSYLVANIA OFFICE OF ATTORNEY GENERAL Tobacco Enforcement Section 15th Floor Strawberry Square Harrisburg, PA 17120 Phone: (717) 783-1794 http://www.attorneygeneral.gov NON - PARTICIPATING MANUFACTURER CERTIFICATION FORM Complete all fields or indicate N/A Do not leave blanks. Please review all instructions for further information. Failure to provide all necessary information will result in the rejection of your certification. PART I: Company Name Address Tobacco Product Manufacturer Identification City Telephone Number State Zip Code Fax Number Web Address Country Email Address Designated to Accept All Official Communication Factory Addresses & Names of Plant Managers (use additional sheets if necessary) Phone Numbers of Plant Managers Manufacturer's Federal Taxpayer ID# Name of Importer Importer's Address Importer's Federal Taxpayer ID# This US Customs ID# Form is (check one): Annual Certification (due April 30 for Pennsylvania sales in the previous year) Supplemental Certification (changes to information on previously submitted forms) Quarterly Certification (Manufacturers required to file each quarter) Initial Certification (Manufacturer not currently listed on Pennsylvania's directory) Initial Certifications will require additional documentation. PART II: General Questions for the Manufacturer (attach additional sheets if necessary) 1. Are you the actual manufacturer (i.e. fabricator) of the brands listed in this certification? Yes No If "No," please explain your reason for certifying. TES - 006 (03/13) Page 1 of 12 Incomplete or illegible certifications will not be processed American LegalNet, Inc. www.FormsWorkFlow.com 2. Are you the Trademark Owner of the brands listed in this certification? Yes If "Yes," attach a copy of your active trademark registration. No If "No," provide the name and contact information of the owner and attach an executed copy of the exclusive manufacturing agreement. Trademark Registration Attached or, Executed Agreement Attached 3. Attached a copy of the Federal Trade Commission (FTC) approval letter for the current year for all brands listed in this certification? Yes No If "No," please explain why it is not available. 4. Attached a copy of the U.S. Centers for Disease Control (CDC) ingredient listing compliance letter for the current year for all of the brands listed in this certification? Yes No If "No," please explain why it is not available. 5. Have you ever had an enforcement action taken against you? Yes No If "Yes," list the state(s) involved and a detailed explanation. (Attach additional sheets if necessary.) 6. Have you ever been denied Directory Listing in any other state or commonwealth? Yes No If "Yes," list the state(s) involved and a detailed explanation. (Attach additional sheets if necessary.) 7. Attached a copy of the PA Department of Revenue's Cigarette Manufacturer Certificate for fire safe cigarettes. Yes No 8. Are you registered with the PA Department of Revenue in accordance with the federal Prevent All Cigarette Trafficking Act/Jenkins Act 15 U.S.C § 375 378? Yes No Verification will be made with the PA Department of Revenue. 9. Are you current with your monthly report filings to the PA Department of Revenue in accordance with the federal Prevent All Cigarette Trafficking Act/Jenkins Act 15 U.S.C § 375 378? Yes No Verification will be made with the PA Department of Revenue. TES - 006 (03/13) Page 2 of 12 Incomplete or illegible certifications will not be processed American LegalNet, Inc. www.FormsWorkFlow.com INITIAL CERTIFICATIONS ONLY (Annual Certifications check N/A) 1. Attached a photograph and diagram of the manufacturing facility? Yes No N/A If "No," please explain why it is not available. 2. Attached a copy of the company's organizational chart? Yes No N/A If "No," please explain why it is not available. 3. Attached a copy of a qualified escrow agreement? Yes No N/A If "No," please explain why it is not available. 4. CSA Distributor - New Non-Participating Manufacturers must secure a CSA/Distributor and initiate sales within six (6) months of Directory Listing. Failure to do so will result in removal from the PA Directory. Name of Distributor PART III: Brand Family Identification (attach additional sheets if necessary) Provide an electronic color copy of every brand style or promotional packaging. Include views of each side of the packaging with UPC clearly visible. Section A. Brands Currently Certified and on the Directory List brands and styles that will remain on the Directory Brand Style Flavor Filter/Non Package Indicate with an asterisk(*) any brands previously sold that are not being sold in the current year. Section B. Brands to be Removed from the Directory List brands and styles currently on the Directory that will no longer be certified. Brand Style Flavor Filter/Non Package TES - 006 (03/13) Page 3 of 12 Incomplete or illegible certifications will not be processed American LegalNet, Inc. www.FormsWorkFlow.com Section C. Additional Brands to be Certified List additional brands and styles to be added to the Directory. List the Brand and Stamping Agent. If a brand family has been manufactured by more than one manufacturer, on a separate sheet of paper provide the name and address of every other tobacco product manufacturer and the dates the brand was produced by each manufacturer. Brand Style Flavor Filter/Non Package Brand Families PA Licensed Cigarette Stamping Agent Section D. Yearly Sales History Manufacturers who file annually should complete the following table with information using the previous year's sales. Manufacturers who file quarterly should complete the table using the previous quarter sales. List your brand families, distributors/CSAs and the number of sticks Pennsylvania last year. If you were not the sole manufacturer of a brand sheet provide the name and address of every other manufacturer and the by each manufacturer. Brand Family· PA Licensed Cigarette Stamping Agent that were sold into family, on a separate dates of manufacture Number of Sticks Sold to each CSA Total Units Sold ·Indicate with an asterisk(*) any brands previously sold that are not being sold in the current year. PART IV: Residency Status The undersigned certifies that the above-named Tobacco Product Manufacturer (check one): is a resident of the Commonwealth of Pennsylvania has appointed the registered agent identified below for service of process in the Commonwealth of Pennsylvania Resident
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