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Non-Participating Manufacturers Appointment Of Registered Agent Form. This is a Oregon form and can be use in Office Of Attorney General Statewide.
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NON-PARTICIPATING MANUFACTURER’S (NPM) APPOINTMENT OF REGISTERED AGENT
FOR STATE OF OREGON AND REGISTERED AGENT’S STATEMENT
Please print or type in permanent dark ink
Sign, date, and return original to:
Office of the Attorney General for the State of Oregon
Oregon Department of Justice
Civil Enforcement Division; Attn: Tobacco Enforcement
1162 Court Street, NE
Salem, OR 97301-4096
NON-PARTICIPATING TOBACCO MANUFACTURERS:
The undersigned Non-Participating Manufacturer (“NPM”) __________________________________ hereby
appoints________________________________________________________________________ as its registered
agent to receive service of process on our behalf; said registered agent is authorized to receive service of process on
behalf of the NPM. The undersigned NPM also agrees to do the following: (1) provide notice to the Office of the
Attorney General for the State of Oregon (“Attorney General”), at least 30 calendar days prior to termination of the
authority of the registered agent; and (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 with proof to the Attorney General of the appointment of
a new agent and a new Non-Participating Manufacturer’s (NPM) Appointment of Registered Agent for State of Oregon
and Registered Agent’s Statement form.
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 Oregon 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 ORS 323.800 to 323.806 or ORS 180.400 to 180.455 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: _________________________________________________________________________________
Principal 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 the within 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.
Signature _________________________________________________
My Commission expires: _______________________
Non-Participating Manufacturer Certification – Statement of Registered Agent
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NAME AND ADDRESS OF OREGON STATE REGISTERED AGENT:
Name: ______________________________________________________________________________________
Street Address (Required – Must be within Oregon): ____________________________________________
PO Box (Optional – Must be in same city as street address): ______________________________________
City & State: _______________________________________________ Zip Code: ________________
Telephone _________________________________________
I consent to serve as Registered Agent in the State of Oregon for the above named NPM, pursuant to ORS 323.800 to
323.806 or ORS 180.400 to 180.455. 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 the within 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.
Signature _________________________________________________
My Commission expires: _______________________
CEDF0412/32206
Non-Participating Manufacturer Certification – Statement of Registered Agent
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