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Certification For Listing On New Mexico Directory (Complimentary Legislation Compliance Form) - New Mexico
|Certification For Listing On New Mexico Directory (Complimentary Legislation Compliance Form) Form. This is a New Mexico form and can be used in Tobacco Product Compliance Office Of The Attorney General Statewide .||
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STATE OF NEW MEXICO Tobacco Product Manufacturer Certification for Listing on New Mexico Directory Pursuant to NMSA §§ 6-4-14 to 6-4-24 Mail this completed certification and all attachments to: Office of the New Mexico Attorney General Attn: Tobacco Project (courier delivery address) 408 Galisteo Street Santa Fe, NM 87504 (U.S.P.S. delivery address) P. O. Drawer 1508 Santa Fe, NM 87504-1508 MARK ONE: Initial______________ Supplemental_______ Renewal____________ Are you requesting any new brands to be added this year?___________ SALES YEAR 2011 PART I: TOBACCO` PRODUCT MANUFACTURER IDENTIFICATION (attach additional sheets if necessary to provide complete responses) 1. Applicant Tobacco Product Manufacturer Identification Applicant:______________________________________________________________ Street Address:_________________________________________________________ City, State, Zip code_____________________________________________________ Mailing Address (if different from above)____________________________________ Phone Number:____________________ Facsimile (FAX) Number:_______________ E-Mail Address:_________________________________________________________ Website Address:________________________________________________________ Page 1 of 12 New Mexico 2012 Certification NMAGO-2012 (1) American LegalNet, Inc. www.FormsWorkFlow.com Name/Title of Person Completing Certification:_______________________________ Manufacturing Plant(s) Name and Street Address (if different from above) ______ Manufacturing Plant Phone Number:________________________________________ Manufacturing Plant Facsimile (FAX) Number________________________________ Name/Title/Phone Number of Person at Plant if different from above:____________ Please attach a photograph(s) and a diagram(s) of your manufacturing facility and indicate on the diagram(s) where the equipment and facilities for manufacturing (i.e., fabricating) the tobacco product(s) are located. 2. The undersigned certifies that as of the date of this Certification, the above-named applicant is: (initial one): _____ A Participating Manufacturer ("PM") under the Tobacco Master Settlement Agreement ______ a Nonparticipating Tobacco Product Manufacturer ("NPM") in full compliance with New Mexico Statutes having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales, including any quarter deposits the applicant was notified it was required to make. If the applicant was notified by the New Mexico Attorney General that it is required to place funds into escrow and the applicant did not timely do so, provide a full explanation for each failure to timely deposit. 3. Applicant is located outside of the United States Yes_____ No_____ If the answer above is "yes", each and every importer of your brands into the United States must provide a declaration acceptable to the New Mexico Attorney General, accepting joint and several liability with applicant for all escrow deposits due, for all penalties assessed and for all payment of costs and attorney fees imposed in accordance with NMSA 1978, §§ 6-4-12 6-4-24. Importers likewise must appoint a resident agent for service in New Mexico and provide evidence of such appointment with the declaration. 3. Applicant is the manufacturer (i.e. fabricator) of the brands listed on 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. _______ Yes _______ 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 2 of 12 New Mexico 2012 Certification NMAGO-2012 (1) American LegalNet, Inc. www.FormsWorkFlow.com 4. Applicant is the first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States. ______ Yes ______ No If the answer is "Yes", identify each cigarette manufacturer (i.e. 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. _____________________________________________________________________________ 5. Applicant is a successor of an entity described in questions 3 or 4 above (i.e., manufacturer or first importer). _______ Yes _______ No 6. If applicant answered "no" to questions 3, 4, and 5 above, explain the basis for applicant's claim that it is a Tobacco Product Manufacturer as defined in NMSA 1978, § 6-4-12 I. 7. Indian Tribe Affiliation Please answer the following questions by marking yes or no after each question. Is applicant an Indian Tribe? Is applicant a federally recognized Indian Tribe? _____ yes _____ yes _____ no _____ no _____ no _____ no _____ no Is applicant a corporation formed under Tribal Law? _____ yes Is applicant affiliated with an Indian Tribe? _____ yes Is applicant owned by members of an Indian Tribe? _____ yes Does applicant have a facility or business premises Located on Tribal land? _____ yes Does applicant have or make a claim of Tribal Sovereign immunity? _____ no _____ yes _____ no If your answer to any of these questions is "yes", you must provide the information requested below and contact the New Mexico Attorney General's Office, 408 Galisteo St., Santa Fe, NM 87501, to make arrangements to execute required waivers of sovereign immunity in order to appear on the New Mexico Attorney General's Directory. __________________________________________________________________________ Full Name of Tribe Mailing Address of Tribal Headquarters Page 3 of 12 New Mexico 2012 Certification NMAGO-2012 (1) American LegalNet, Inc. www.FormsWorkFlow.com Telephone Number for Tribal Headquarters 8. Licenses/Permits: a. New Mexico Department of Taxation and Revenue License Number (as a manufacturer or importer)_______________ Please list any additional licenses obtained from the New Mexico Department of Taxation and Revenue and their numbers?_______________________________ Attach copies of all current and valid licenses from the New Mexico Department of Taxation and Revenue. b.