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This is a Oregon form that can be used for Civil Enforcement Division within Statewide, Office Of Attorney General.
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State of Oregon Manufacturer Certification For Listing on the Oregon Smokeless Tobacco Directory Part 1: Year and Type of Certification Year for this Certification: Type of Certification (check one): Part 2: Manufacturer Identification Applicant Company Name: Mailing Address: City: Phone: State: Fax: Zip: Email: Country: 20 Initial Annual Supplemental Name of Person Completing Certification: Part 3: Manufacturing Facility Information Plant Name: Physical Address: Plant Phone: Plant Fax: Name/Title of Person at Plant (if different than above): Part 4: Brand Family and Brand Style Identification A. Brand Family and Brand Styles: For each brand style for which Applicant is seeking certification or for which Applicant received certification in a prior year, the following information is attached: Name: List the brand family and brand style (those brand styles that will not be sold in the current year should be marked with an asterisk (*)). Moist Snuff or Chewing Tobacco: Indicate whether the product is moist snuff or chewing tobacco. B. Additional Information: Check the appropriate box(es): Initial or Supplemental Certification: Included with this Certification is corresponding actual moist snuff or chewing tobacco packaging (without tobacco) for each Brand Style for which Applicant requests certification. Annual Certification No Packaging Changes: Corresponding actual moist snuff or chewing tobacco packaging (without tobacco) has been previously provided and there have been no changes to the packaging. Annual Certification Packaging Changes/Brand Additions: There have been changes to the packaging samples previously submitted or new brand styles have been added. Corresponding actual moist snuff or chewing tobacco packaging (without tobacco) is included. Part 5: Manufacturer Status The Manufacturer listed in Part 2 of this application is (check one): A participating manufacturer, under the Smokeless Master Settlement Agreement. Do not complete Parts 6, 7, or 8 of this application. An escrow-exempt manufacturer, pursuant to the Master Settlement Agreement or other relevant settlement agreement. Do not complete Parts 6, 7, or 8 of this application. A nonparticipating manufacturer, as defined in ORS 180.468(2). Complete all parts of this application. Smokeless Tobacco Manufacturer Certification Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 6: Non-Participating Manufacturer's Certification and Election under ORS 323.816 The Manufacturer listed in Part 2 of this application certifies that it is in full compliance with ORS 323.816, by electing to (check one): Comply with the requirements imposed on Participating Manufacturers that are set forth in sections III (except for section III(m)) and VII of the Smokeless Tobacco Master Settlement Agreement. (Do not complete Part 7. Complete Parts 8 and 9 of this application). Place into a qualified escrow fund, by April 15 of the year following the year in question, the amount of $0.40 per unit sold for 2010 or such amount adjusted for inflation for each year thereafter. (Complete all parts of this application) Part 7: Qualified Escrow Fund and Financial Institution The Applicant certifies that at the time of this Certification, the Applicant has: Enclosed the completed Annual Escrow Compliance Certificate and Affidavit for the prior year's sales in Oregon. Established and continues to maintain a Qualified Escrow Fund as defined in ORS 323.810(3) and said fund complies with ORS 323.810 to 323.816. Executed a Qualified Escrow Agreement that has been reviewed and approved by the Attorney General for the State of Oregon and that governs the Qualified Escrow Fund for the State of Oregon. A copy of the current Qualified Escrow Agreement, including any amendments, is attached. Ensured that the escrow funds held in the Qualified Escrow Fund on behalf of the State of Oregon are in a separate segregated account, separate and apart from escrow funds held on behalf of any other beneficiary. Ensured that the Qualified Escrow Fund is not encumbered by a security interest granted to a third party. Attached information documenting all deposits and withdrawals from the Qualified Escrow Fund during the last year and attached proof of the current escrow account balance from the Escrow Agent. Name of Financial Institution Contact Agent Name Mailing Address: Escrow Account No. Oregon Sub-Acct. No. Phone No. Fax No. Part 8: Registered Agent/Approved Agent for Service of Process The Applicant (check one): Is registered to do business in the State of Oregon; or Has appointed a resident agent for service of process in the State of Oregon and provided notice of the appointment to the Attorney General for the State of Oregon by submitting a completed NonParticipating Manufacturer's Appointment of Registered Agent for State of Oregon and Registered Agent's Statement, which can be found at www.doj.state.or.us Smokeless Tobacco Manufacturer Certification Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 9: Execution by Authorized Agent Under penalty of perjury, I certify that all of the statements and information contained in this Certification, including but not limited to any accompanying statements or attachments herewith, are true, correct, accurate and complete in every particular and that I am a person authorized to bind the Tobacco Product Manufacturer making this Certification either under the laws of the State of Oregon or of the jurisdiction where the manufacturer resides or is organized. Any violation of the requirements of ORS 323.810 to 323.816 or ORS 180.465 to 180.494 is a basis for removal of the Applicant's Brand Families from the Oregon Directory of Compliant Smokeless Tobacco Product Manufacturers and Brands. The Applicant/Tobacco Product Manufacturer hereby submits itself to the jurisdiction of the Circuit Court of the County of Marion, Oregon, for purposes of all litigation arising out of this certification or the sale of smokeless tobacco products in Oregon. *** This Certification must be signed and dated before an authorized notary public *** Signature of Authorized Person: Printed Name of Authorized Person: Subscribed and sworn to or affirmed before me on this date: Signature of Notary Public: Seal of Notary Public: County of: My commission expires: Title: Date: Mail the completed original Non-Participating Manufacturer's Certification and all supporting documents to: Office of the Attorney General Oregon Department