Certification For Listing In The Connecticut Tobacco Directory {TPM-2}

en-USState of Connecticuten-USForm TPM-2en-USen-USen-USThis application will not be processed or considered complete until all the information and documents required, either by the application en-USen-US en-USen-USFor completion by participating manufacturers (PMs) and nonparticipating manufacturers (NPMs) þ en-US þ en-US þ þ en-US þ þ en-US þ en-US þ en-US þ en-US þ en-US þ þ en-US þ þ en-US þ en-US þ en-US þ en en-USen-USen-USs (interior and exterior of facility, and photos of equipment used in manufacturing/fabrication) and en-USdiagram of the en-USen-US þ en-US(initial one)en-US þ en-US en-USen-US en-US þýýý þ þ en-USen-US en-US þ en-US en-USen-USen-USen-USen-USen-USen-USYes þ en-US þ en-USNoen-USen-US þ en-US þ en-US þ en-US þ en-USSupplementalen-USen-USen-US) þ 226 þ 226 þ 226 þ 226 þ 226 þ 226 þ 226 þ 226 American LegalNet, Inc. www.FormsWorkFlow.com þ en-USen-USen-USYes þ en-US þ en-USNoen-USen-USen-US, identify each cigarette manufacturer (fabricator), the plant street address, mailing address, contact person, en-US en-USen-USen-US þ þ þ þ þ þ þ þ þ en-US Yes þ þ en-US þ en-USNo þ en-USen-US þ þ þ þ þ þ þ þ þ þ þ en-USen-US en-USen-USen-US þ þ þ þ þ þ þ þ þ þ en-US American LegalNet, Inc. www.FormsWorkFlow.com þ þ en-USen-USen-USYes þ en-US þ en-USNo þ en-USen-USen-USen-USinformation for en-USen-US and en-USen-US en-US en-US en-US þ en-USen-US. þ en-US þ þ þ en-USen-USwith the license application?en-US Yes þ þ en-US þ en-USNoen-US þ en-USen-US þ þ þ þ þ þ þ þ en-USen-USDen-US. þ en-USen-USen-US þ þ en-USof certain cigarettes)?en-US Yes þ þ en-US þ en-USNo þ þ en-US Yes þ þ en-US þ en-USNoen-USen-USen-US American LegalNet, Inc. www.FormsWorkFlow.com þ en-US en-US en-USen-US en-USen-US þ þ þ þ þ þ þ en-US þ þ en-US þ en-US Yes þ þ en-US þ en-US þ en-USen-USen-USen-USen-US, explain and attach any related en-US American LegalNet, Inc. www.FormsWorkFlow.com en-USen-USFor completion by PMs and NPMs þ en-USen-USen-USen-USSamples of the actual packaging and labeling must be submitted for each brand family not on the Connecticut Tobacco Directory as þ en-USPlease provide a current listing of all en-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-US en-USen-USen-US en-USen-US en-USen-USen-USen-US en-USen-US en-USen-USen-USen-US en-US en-USen-US en-USen-USen-US en-USen-US þ þ en-US American LegalNet, Inc. www.FormsWorkFlow.com en-USen-USFor completion by NPMs only þ þ en-US þ þ en-USowneren-USen-USen-US þ en-USen-US þ þ Please indicate whether the following statements describe the applicant by checking either en-USen-US or en-USen-USen-US en-US þ þ en-US en-USen-USen-US Yes en-USen-US No þ þ þ en-USen-USen-US Yes en-USen-US No en-USen-USen-USen-US en-USen-USen-USStreet addressen en-USTelephone numberen-USFax numberen-USDate and place of birthen-USEmail addressen-USTitle or relationship to applicanten-USen-USen-USowner of any other PM or NPM?en-USen-USen-US, identify the PM(s) or NPM(s) en-USen-US en-US Yes þ þ en-US þ en-USNo en-US Yes þ þ en-US þ en-USNo en-US Yes þ þ en-US þ en-USNo American LegalNet, Inc. www.FormsWorkFlow.com en-USen-USFor completion by NPMs only þ þ þ en-US en-USen-US en-USen-US en-USen-USen-US en-USen-US en-USen-US en-USen-USen-USen-US en-USen-USen-US en-US þ þ en-USen-USen-USen-US en-US þ en-USYes en-US þ No en-US þ en-USYes en-US þ No en-US þ en-USYes en-US þ No en-US þ en-USYes en-US þ No en-US þ en-USYes en-US þ No en-US þ en-USYes en-US þ No en-US þ þ þ þ en-US þ þ þ en-USsupporting the total sales number en-USen-US þ þ þ en-USthe total sales number en-USen-US þ þ en-US þ en-US þ en-US þ þ en-US American LegalNet, Inc. www.FormsWorkFlow.com en-USen-USFor completion by NPMs only þ þ en-US en-US en-US þ en-US þ þ en-USen-US en-US en-US en-US en-USen-US þ en-US þ For each brand family, list the name and address of the entity which submitted the ingredient reporting information to the en-US en-USen-US en-USen-US þ en-US en-US en-US en-US American LegalNet, Inc. www.FormsWorkFlow.com en-US þ en-US þ For each brand family, list the name and address of the person, company, or entity that placed the cigarettes into packages with the en-US en-US en-US en-US en-USen-USen-USen-USen-USFor completion by NPMs only þ þ þ þ þ þ þ en-USen-USen-USen-USen-USen-USNoen-USen-US þ þ þ þ þ þ en-US þ þ en-US þ þ þ þ en-USanswer en-USen-USen-USen-USNoen-USen-US þ þ þ þ þ þ þ en-USen-USen-USen-USen-USen-USNoen-USen-US þ þ þ þ þ þ en-US þ en-USanswer en-USen-USen-USen-USNoen-USen-US American LegalNet, Inc. www.FormsWorkFlow.com en-US þ en-USen-US þ þ þ þ þ en-US þ en-USby any government entity (federal, state, local, or foreign) or ever had any such permit, license, or other authorization revoked, en-USen-USen-US if the denial, revocation, suspension, or other termination of such a permit, en-USen-USen-USNoen-USen-USen-USen-US þ þ þ þ þ þ en-US þ en-USen-USen-USen-USNoen-USen-USen-US þ þ þ þ þ en-US þ en-US þ en-USen-USen-USen-USNoen-USen-US þ en-US þ þ þ þ þ en-US en-USever entered into any agreement or settlement with any state relating to whether it has made adequate or timely escrow deposits as þ en-USen-US if any en-USen-USen-USNoen-USen-USen-USen-USFor completion by NPMs onlyen-US þ en-US þ en-US þ þ þ þ þ þ en-USen-US þ þ þ þ American LegalNet, Inc. www.FormsWorkFlow.com en-USen-USFor completion by NPMs or their en-US þ þ þ þ en-USen-US Yes en-USen-US No þ þ þ en-USen-US Yes en-USen-US Noen-USen-US þ en-USa completed Form TPM þ - 4 en-US, en-USNotice of Appointment of Registered Agent and Registered Agent222s Statementen-USen-USattachen-US. þ þ þ þ þ en-USen-US Yes en-USen-US No þ þ þ en-USen-US Yes en-USen-US Noen-USen-US þ en-USen-USappoint a resident agent for service of þ þ en-US. en-USThe NPM importer en-US þ þ þ þ þ en-USen-US Yes en-USen-US No þ en-USen-USen-US Yes en-USen-US No þ þ þ þ en-USen-US Yes en-USen-US Noen-USen-USen-US þ en-US en-US en-USen-US en-US en-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-USen-USen-USen-USP en-US American LegalNet, Inc. www.FormsWorkFlow.com en-USen-USFor completion by PMs and NPMsen-USen-US þ en-US þ en-USen-US þ en-USen-US þ en-USen-USen-US þ en-USen-US þ en-US þ en-USen-US þ en-USen-US þ en-US þ en-US þ en-US þ en-US þ en-US þ en-USState of en-US en-USCounty of en-US en-USCountry of en-US en-USOn en-US en-US, before me, en-US en-US, personally appeareden-US en-US en-US, personally known to me (or proved to me on the basis of satisfactory evidence) en-USto be the person whose name is subscribed to the within instrument and acknowledged to me that he or she executed the same in his en-USor her authorized capacity and that by his or her signature(s) on the instrument the person or the entity upon behalf of which the person en-USen-USen-US þ en-US þ en-USen-USen-USen-USDepartment of Revenue Servicesen-US en-USen-USExcise/Public Services Subdivisionen-US en-USen-US en-USen-US en-USen-USen-USFinance Departmenten-USen-US þ 226 þ 226 American LegalNet, Inc. www.FormsWorkFlow.com