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Tobacco Product Manufacturer Certification (Non-Participating Manufacturers) TT-19-NPM - Virginia

Tobacco Product Manufacturer Certification (Non-Participating Manufacturers) Form. This is a Virginia form and can be used in Tobacco Section Office Of Attorney General Statewide .
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FORM TT-19-NPM COMMONWEALTH OF VIRGINIA Tobacco Product Manufacturer Certification for Non-Participating Manufacturers Part 1: Type of Certification (check one) Initial Certification Annual Certification Filed in Year _______ (Due by April 30 each year) Supplemental Certification (Due thirty (30) days prior to any desired change in Certification) Part 2: Tobacco Product Manufacturer Identification Full Legal Name: Type of Business Entity (check one): Sole Proprietorship General Partnership Limited Partnership Corporation Limited Liability Company Other (specify): _____________________________ State/Country where Created, Incorporated or Registered: Include with certification: · · A copy of the current Articles of Incorporation, Certificate of Limited Partnership, Articles of Organization, or comparable applicable document, including any amendments, must be attached to the certification. A copy of the Manufacturer's current TTB Tobacco Permit, with any amendments. Trading As (list all names ever used): Federal Employers Identification Number: Federal Tobacco Manufacturer Permit Number: Physical Address: Mailing Address: Company Phone: Contact: Rev. (02/09) Page 1 of 9 American LegalNet, Inc. www.FormsWorkflow.com FORM TT-19-NPM Title: Phone: Email: Fax: Website: Name, Title and Dates of Service for all Current and Past Officers, Directors and/or Partners: If the Tobacco Product Manufacturer is represented by outside counsel for the purpose of compliance with Va. Code § 3.2-4200 et seq., provide the following information: Firm: Attorney: Address: Phone: Email: Part 3: Registered Agent for Service of Process within the Commonwealth of Virginia Agent: Company: Address: Phone: Email: · A current statement from the registered agent certifying service in this capacity must be attached to the Certification. Fax: Fax: Rev. (02/09) Page 2 of 9 American LegalNet, Inc. www.FormsWorkflow.com FORM TT-19-NPM Part 4: Fabricator Identification The Tobacco Product Manufacturer fabricates its own cigarettes. The Tobacco Product Manufacturer uses a fabricating facility that is separate from the Manufacturer itself. If the Tobacco Product Manufacturer utilizes a fabricating facility that is separate from the Tobacco Product Manufacturer itself, provide the following information: Fabricating Facility Name(s) (if different from Tobacco Product Manufacturer):_____________________ _____________________________________________________________________________________ Physical Address:_______________________________________________________________________ _____________________________________________________________________________________ Mailing Address: _______________________________________________________________________ _____________________________________________________________________________________ Fabricating Plant Phone: ______________________________________________________________ Contact:______________________________________________________________________________ Title: ________________________________________________________________________________ Phone: _________________________________ Fax: _________________________________________ Email: __________________________________ Website: _____________________________________ · · A photograph or diagram of the Tobacco Product Manufacturer's fabricating facility must be attached to the Certification. Identify in the diagram where the equipment and facilities for manufacturing the Brand Family(s) are located. A list of every Brand Family the Tobacco Product Manufacturer has fabricated, or caused to be fabricated by another entity, since July 1, 1999 must be attached to the Certification. Indicate with an asterisk (*) any Brand Family not being sold in the current year, and identify whether such Brand Family is still being manufactured and by what entity. Part 5: Disclosure of Enforcement Actions and Prior Determinations (check any that may be applicable) The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has had any of its cigarettes banned or enjoined from sale by any state or federal court or administrative agency. · If the above is applicable, for each such enforcement action a copy of any case decision and the following information must be attached to the Certification: (1) the Brand Family(s) banned and/or enjoined; (2) the governmental entity (federal, state, local or foreign) or official bringing the action; (3) the case number; and (4) the name and address of the government attorney or official that brought the action. Page 3 of 9 American LegalNet, Inc. www.FormsWorkflow.com Rev. (02/09) FORM TT-19-NPM The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has been denied a permit or license, or been denied any other authorization to engage in business relating to the sale of cigarettes by any government entity (federal, state, local or foreign) or had such permit, license or other authorization revoked, suspended, or otherwise terminated. · If the above is applicable, for each such denial, revocation, suspension or termination of a permit, license or other authorization a copy of any case decision and the following information must be attached to the Certification: (1) the name of the person or entity that had such permit, license or other authorization revoked, suspended or otherwise terminated; (2) the governmental entity (federal, state, local or foreign) that denied, suspended or revoked such permit, license or other authorization; (3) the case number; and (4) the name and address of the government attorney or official that brought the action. The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has been · convicted of any crime under federal, state, or foreign law in connection with the sale of cigarettes. If the above is applicable, for each such conviction a copy of any case decision and the following information must be attached to the Certification: (1) the name of the person or entity convicted; (2) the governmental entity (federal, state, local or foreign) that prosecuted the action; (3) the case number; and (4) the name and address of the government attorney or official that prosecuted the action. The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has been involved as an officer or owner of any other Tobacco Product Manufacturer. · If the above is applicable, the name of the other
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