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Non Participating Manufacturer Certification Form - Kansas
| Non Participating Manufacturer Certification Form Form. This is a Kansas form and can be used in Tobacco Manufacturer Attorney Generals Office Statewide . |
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OFFICE OF THE KANSAS ATTORNEY GENERAL NON-PARTICIPATING MANUFACTURER CERTIFICATION FORM REVISED JANUARY 25, 2012 TYPE OF CERTIFICATION This certification is: Initial Supplemental Renewal MANUFACTURER INFORMATION Manufacturer: Mailing Address: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Street Address: ____________________________________________________________ ____________________________________________________________ The street address should be the physical location of the manufacturing plant. Phone Number: E-Mail Address: Website: Federal Taxpayer ID Number: ________________________ Fax Number: ___________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Only applies if manufacturer is registered in the United States. Non-Participating Manufacturer Certification Form Revised January 25, 2012 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com IMPORTER INFORMATION Complete this section only if you are a manufacturer located outside of the United States. Importer Name: Contact Name: and Title: Mailing Address: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Phone Number: E-Mail Address: Federal Taxpayer ID Number: ________________________ Fax Number: ___________________ ____________________________________________________________ ____________________________________________________________ Important Notice: Pursuant to K.S.A. 50-6a04(c)(3)(I), manufacturer must submit an original United States Importer Declaration Form executed by each entity who imports any of its brand families into the United States to be sold in Kansas. The form is available at www.ksag.org/tobacco. DESIGNATED CONTACT Identify the person that you wish to receive all correspondence and official notifications. Failure to designate an official contact person will result in an incomplete certification. Contact Name: Organization: Relationship to Manufacturer: Mailing Address: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ E.g., Attorney, Importer, Tax Compliance Manager, etc. ____________________________________________________________ ____________________________________________________________ Phone Number: E-Mail Address: ________________________ Fax Number: ___________________ ____________________________________________________________ Non-Participating Manufacturer Certification Form Revised January 25, 2012 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com RESIDENT AGENT FOR SERVICE OF PROCESS Resident Agent: Mailing Address: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Phone Number: E-Mail Address: ________________________ Fax Number: ___________________ ____________________________________________________________ ESCROW FUND INFORMATION Financial Institution: ____________________________________________________________ Contact Name and Title: Address: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Phone Number: E-Mail Address: Primary Escrow Account Number: ________________________ Fax Number: ___________________ ____________________________________________________________ ____________________________________________________________ Kansas SubAccount Number(s): ____________________________________________________________ Execution Date of Most Recent Escrow Agreement: ____________________________________________________________ Amount Deposited Into Escrow For Previous Sales Year (1s 4th Quarter 2011): ____________________________________________________________ Total Units Sold in Previous Sales Year (1st4th Quarter 2011): ____________________________________________________________ Non-Participating Manufacturer Certification Form Revised January 25, 2012 Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com BRAND FAMILIES TO BE CERTIFIED Complete this page for each brand family you wish to certify for sale in Kansas. Only list one brand family per sheet. Attach additional sheet(s) as needed. PLEASE IDENTIFY: PAGE ____ OF _____ BRAND FAMILY INFORMATION Brand Family: _______________________________ Cigarette RYO (Check one only.) CURRENT MANUFACTURER (Check appropriate box below. You MUST choose one.) The certifying manufacturer actually manufactures the brand family identified above. A different manufacturer, other than the certifying manufacturer, actually manufactures the brand family identified above. Attach a copy of all contract manufacturing agreements between the certifying manufacturer and the actual manufacturer for the brand family identified above. OTHER MANUFACTURERS (Check appropriate box below. You MUST choose one.) Provide the name and address of any manufacturer(s), other than the certifying manufacturer, who actually manufactured the brand family identified above at any time between January 1, 2011, and the current date. Name: Address: Not applicable. TRADEMARK INFORMATION (Check appropriate box below. You MUST choose one.) Manufacturer owns a United States Registered Trademark for the brand family identified above. Trademark serial or registration number: ____________________________________ ____________________________________________________________ ____________________________________________________________ Manufacturer does not own a United States Registered Trademark for the brand family identified above. Attach any written contracts or agreements indicating the authority to manufacture the brands, or written authorization from the trademark holder. Trademark serial or registration number: ____________________________________ A United States Registered Trademark does not exist for the brand family identified above. Non-Participating Manufacturer Certification Form Revised January
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