Appointment Of Registered Agent And Registered Agents Statement

Montana Department of Justice Appointment of Registered Agent for State of Montana Page 1 of 2 Revised February 2018 and Registered Agent's Statement MONTANA DEPARTMENT OF JUSTICE APPOINTMENT OF REGISTERED AGENT FOR STATE OF MONTANA AND REGISTERED AGENT'S STATEMENT Please type or print in permanent dark or blue ink Sign, date, and return original to: Montana Attorney General's Office of Consumer Protection Attn: Tobacco Enforcement Program PO Box 200151 Helena, MT 59620-0151 The undersigned NPM hereby appoints as its registered agent to receive service of process on its behalf; the registered agent is authorized to receive service of process on behalf of the NPM. The undersigned NPM agrees to do the following: (1) provide notice to the Montana Attorney General's Office ("Attorney General"), at least 30 calendar days prior to termination of the authority of the registered agent; (2) provide proof to the satisfaction of the Attorney General of the appointment of a new agent at least five calendar days prior to the termination of an existing agent appointment. The undersigned NPM further agrees that, if the agent terminates its agency appointment, the undersigned shall provide notice to the Attorney General of the termination within five calendar days and shall include proof to the Attorney General of the appointment of a new agent. Under penalty of perjury, I certify and declare 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 NPM making this Certification either under the laws of the State of Montana or of the jurisdiction where the manufacturer resides or is organized, and I have attached an authentic, certified copy of document(s) as proof of my authority to bind the NPM. Any violation of the requirements of Mont. Code Ann. 247247 16-11-401 through 16-11-404 or 247247 16-11-501 through 16-11-512 is a basis for removal of the applicant's Brand Families from the list of compliant NPMs. ~~ This Certification must be signed and dated by an authorized notary public. ~~ Signature of Designee for Non-Participating Manufacturer: Designee (Print Name): Title: Principle Place of Business (physical address): STATE OF ) COUNTY OF ) COUNTRY OF ) On before me, , personally appeared , personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to this instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. (SEAL) Signature Printed Name Residing at: My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com Montana Department of Justice Appointment of Registered Agent for State of Montana Page 2 of 2 Revised February 2018 and Registered Agent's Statement NAME AND ADDRESS OF MONTANA STATE REGISTERED AGENT: Name: Street Address (Required 226 Must be within Montana) PO Box (Optional 226 Must be in same city as street address) City & State: Zip Code: Telephone: FAX Number: E-mail Address: I consent to serve as Registered Agent in the State of Montana for the above-named NPM, pursuant to Mont. Code Ann. 247 16-11-506. I understand it will be my responsibility to receive Service of Process on behalf of the NPM; to forward mail to the NPM; and to immediately notify the Office of the Attorney General if I resign or change the office address of the Registered Agent. ~~ This Certification must be signed and dated by an authorized notary public. ~~ Signature: Date: Print Name: Title: STATE OF ) COUNTY OF ) COUNTRY OF ) On before me, , personally appeared , personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to this instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. (SEAL) Signature Printed Name Residing at: My Commission Expires: Montana Code Annotated Title 16, Chapter 11, Part 5 American LegalNet, Inc. www.FormsWorkFlow.com