Tennessee > Statewide > Attorney General > Tobacco Settlement
NPM Information Request - Tennessee
| NPM Information Request Form. This is a Tennessee form and can be used in Tobacco Settlement Attorney General Statewide . |
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State of Tennessee NPM Information Request Pursuant to Tenn. Code Ann. §§ 67-4-2601 et seq. Please type or legibly print in permanent blue ink. Use additional pages as necessary. (This Form may be filled out on-line, however, all signatures must be executed in permanent blue ink.) Applicant name: Street Address: City/State/Zip/Country: Mailing Address (if different from above): City/State/Zip/Country: Telephone number: E-mail address: Facsimile number: Official TN Form 114780 March 15, 2012 Page 1 of 4 The following documents must be attached to your 2012 Certification Form for Listing on Tennessee's Directory. Initial by each number to confirm that each document requested is attached and labeled appropriately: 1. Samples - Samples (or legible, identical size, color c opies of all sides of t he packaging thereof) of the current packaging and labeling use d for each of the i ndividual brands within each Brand Family listed in Part 3 of the 2012 Certification Form for Listing on Tennessee's Directory. Initial to confirm that you have attached these documents. Permits & Licenses to Manufacture Cigarettes - A copy of all permits, licenses or other authorization to manufacture tobacco products issued by any governmental entity, whether located in the United States or elsewhere. This in cludes importer's certificate, trademark holder's certificate, etc. Initial to confirm that you have attached the requested documents. Certificate of Compliance (cigarettes only) - A copy of t he current Centers for Disease Control (CDC) ingredient-listing compliance letter(s) pertaining to th e brands listed in this certification and a statement from the manufacturer as to whic h brands' ingredients were submitted for each a pproval letter. Initial to confirm that you have attached the requested documents. FTC Warning Rotation Information (cigarettes only) - A copy of the complete current health warning rotation plan submitted to the Fed eral Trade Co mmission ("FTC") pursuant to 15 U.S.C. § 1333 and a copy of the approval letter from the FTC for each brand family applicant wants listed. If the Certification Applicant sells or intends to sell Cigarettes that are not made in the United States, please identify the name and address of th e entity that submitted the ingredient reporting information to the U.S. Secretary o f Health and Human Services. Initial to confirm that you have attached these documents. Brand List - Provide a complete list of all tobacco product Brand Families, (including all cigarettes, rollyour-own, cigars, little c igars, pipe tobacco, sm okeless tobacco, etc.) currently and previ ously manufactured by the (Non-Participating) Manufacturer, its principals, subsidiari es, affiliates, successors, members, officers, owners and directors. This list is in addition to the list provided for certification. List whether or not sold in the U.S., the dates during which each Brand Family is, or was, manufactured, and place of manufacture for those brands. Initial to confirm that you have attached these documents. Trademark Information - A list of the trademark owners, including street address and telephone number for each Bra nd Family identified in the Certification for Listing on Tennessee's Directory. Initial to confirm that these documents are attached. American LegalNet, Inc. www.FormsWorkFlow.com 2. 3. 4. 5. 6. 7. Official TN Form 114780 March 15, 2012 Page 2 of 4 Trademark Holder's Certificate - A copy of the trademark holder's certificate under penalty of perjury that it has not withdrawn consent to import into the United States as required by 19 U.S.C. 1681a(c)(3)(A) or a copy of the importer's certificate under penalty of perjury that the trademark owner has not withdrawn consent to import into the United States as required by 19 U.S.C. 1681a(c)(3)(B). Initial to confirm attachment that these documents are attached. 8. a) Provide four clear color photographs taken within 90 days of this application of at least four inches by six Photographs inches of the exterior of each side of each of your manufacturing facilities. Each of the photographs must provide clear and unobstructed views of each side of the outside of the manufacturing facility(ies). Each photograph must be labeled on the back with the name of the factory, the full street address of the factory, the date of the photograph was taken and the full name, address and telephone number of the person who took the photograph. Initial to confirm that these documents are attached.. inches of the interior of each manufacturing facility. The photographs must provide at a minimum the following: (a) clear and unobstructed views of the majority of the interior of the manufacturing facility, (b) clear and unobstructed views of the number of manufacturing lines and machines in operation in the manufacturing facility, (c) clear and unobstructed views of the manufacturing facility in operation, and (d) clear and unobstructed views of the number of employees normally working in the manufacturing facility when it is in operation. Each photograph must be labeled on the back with the name of the factory, the full street address of the factory, the date of the photograph was taken and the full name, address and telephone number of the person who took the photograph. Initial to confirm that these documents are attachedt. b) Provide five clear color photographs taken within 90 days of this application of at least four inches by six 9. Notice of Appointment of Registered Agent Attach official form number 86971. Fo rm is located online at www.attorneygeneral.state.tn.us/cpro/pdf/gent.pdf. Please also submit a current letter (dated this year) from the registered agent accepting this appointment. Initial to confirm that the form and acceptance letter are attached to this form. Stamping Agent and/or Distributor For each stamping agent or distributor of your products possessing a Tennessee wholesale licens e, please provide the name, address, telephone, facsimile numbers and all brand families delivered to each stamping agent or distributor. Initial to confirm that this information is attached. Delivery Service Information Reports If Applicant advertises or sells Cigarettes via the Internet or in catalogs and uses the mail or other delivery service to deliver Cigarettes to Tennessee Consumers. Please provide a copy o f all D elivery Service Information Reports (RV-F1309001) filed with the Tennessee Department of Revenue during calendar year 2011
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