STATE OF CALIFORNIA JUS-TOB 1 (Rev. 06/2012) DEPARTMENT OF JUSTICE PAGE 1 of 12 CERTIFICATION FOR LISTING ON CALIFORNIA DIRECTORY (REV. & TAX. CODE, § 30165.1) DATE OF APPLICATION: PLEASE TYPE OR FILL OUT IN PERMANENT BLUE INK. INITIAL SUPPLEMENTAL PART I: 1. GENERAL BUSINESS AND OWNERSHIP INFORMATION APPLICANT TOBACCO PRODUCT MANUFACTURER IDENTIFICATION. APPLICANT: STREET ADDRESS: CITY: COUNTRY: MAILING ADDRESS IF DIFFERENT FROM ABOVE: ADDRESS: CITY: COUNTRY: PHONE NUMBER: E-MAIL ADDRESS: NAME/TITLE OF PERSON COMPLETING CERTIFICATION: MANUFACTURING PLANT(S) NAME AND ADDRESS IF DIFFERENT FROM ABOVE: NAME: ADDRESS: CITY: COUNTRY: MANUFACTURING PLANT PHONE NUMBER: MANUFACTURING PLANT FACSIMILE (FAX) NUMBER: STATE: ZIP CODE: FACSIMILE (FAX) NUMBER: WEBSITE ADDRESS: STATE: ZIP CODE: STATE: ZIP CODE: NAME/TITLE/PHONE NUMBER OF PERSON AT PLANT IF DIFFERENT FROM ABOVE: 2. (ATTACH ADDITIONAL SHEET(S), IF NECESSARY, TO PROVIDE COMPLETE RESPONSE.) PLEASE ATTACH A PHOTOGRAPH OR DIAGRAM OF YOUR MANUFACTURING FACILITY AND INDICATE ON THE PHOTOGRAPH OR DIAGRAM WHERE THE EQUIPMENT AND FACILITIES FOR MANUFACTURING (i.e., FABRICATING) THE CIGARETTES, IF ANY, ARE LOCATED. THE UNDERSIGNED CERTIFIES THAT AS OF THE DATE OF THIS CERTIFICATION, THE ABOVE-MENTIONED APPLICANT IS: (INITIAL ONE) A PARTICIPATING MEMBER ("PM"). (IF APPLICANT IS A PM, IT MAY GO DIRECTLY TO QUESTION SEVEN OF PART I.) A NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER ("NPM") IN FULL COMPLIANCE WITH CALIFORNIA'S RESERVE FUND STATUTE (HEALTH & SAFETY CODE SECTIONS 104555-104557) AND IMPLEMENTING REGULATIONS, INCLUDING HAVING MADE ALL REQUIRED DEPOSITS INTO A QUALIFIED ESCROW FUND FOR ALL YEARS BEGINNING WITH YEAR 2000 SALES. 3. APPLICANT IS THE MANUFACTURER (i.e., FABRICATOR) OF THE BRANDS LISTED IN 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 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA JUS-TOB 1 (Rev. 06/2012) DEPARTMENT OF JUSTICE PAGE 2 of 12 CERTIFICATION FOR LISTING ON CALIFORNIA DIRECTORY (REV. & TAX. CODE, § 30165.1) 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. ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE. 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 UNDER SECTION 104556, SUBDIVISION (I), OF THE HEALTH AND SAFETY CODE AND SUBMIT ALL DOCUMENTATION TO SUPPORT APPLICANT'S CONTENTION. ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE. 7. LICENSE/PERMITS ALL APPLICANTS MUST OBTAIN A CIGARETTE AND/OR TOBACCO PRODUCTS MANUFACTURER'S LICENSE(S). (REV. & TAX. CODE, § 30165.1, SUBD. (c)(1)(C).) a. BOARD OF EQUALIZATION (BOE) LICENSE NUMBER AS A MANUFACTURER OR IMPORTER: ADDITIONAL LICENSES OBTAINED FROM THE BOE AND THEIR NUMBERS: ATTACH COPIES OF ALL CURRENT AND VALID LICENSES FROM THE BOE. b. U.S TREASURY, TOBACCO TAX BUREAU (TTB) PERMIT NUMBER AS A MANUFACTURER: AS AN IMPORTER: ATTACH A COPY OF APPLICANT'S CURRENT PERMIT AS A AND/OR PLEASE LIST ANY MANUFACTURER OR IMPORTER PURSUANT TO 26 USC CHAPTER 52, AND REGULATIONS ISSUED THEREUNDER. PART II: 1. BRAND FAMILY IDENTIFICATION BRAND FAMILY IDENTIFICATION. (PMs COMPLETE COLUMN A; NPMs COMPLETE COLUMN A THROUGH C.) A. BRAND FAMILY (INDICATE WITH AN ASTERISK (*) B. UNITS SOLD IN C. MANUFACTURER OF BRANDS LISTED (INCLUDE THOSE BRANDS THAT WILL NOT BE SOLD IN APPLICATION PRECEDING COMPLETE ADDRESS INFORMATION) YEAR) CALENDAR YEAR American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA JUS-TOB 1 (Rev. 06/2012) DEPARTMENT OF JUSTICE PAGE 3 of 12 CERTIFICATION FOR LISTING ON CALIFORNIA DIRECTORY (REV. & TAX. CODE, § 30165.1) 1. BRAND FAMILY IDENTIFICATION, CONT'D. (PMs COMPLETE COLUMN A; NPMs COMPLETE COLUMN A THROUGH C.) A. BRAND FAMILY (INDICATE WITH AN ASTERISK (*) B. UNITS SOLD IN C. MANUFACTURER OF BRANDS LISTED (INCLUDE THOSE BRANDS THAT WILL NOT BE SOLD IN APPLICATION PRECEDING COMPLETE ADDRESS INFORMATION) YEAR) CALENDAR YEAR ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE. ATTACH SAMPLES OF THE ACTUAL PACKAGING AND LABELING OF CARTONS AND PACKS FOR EACH BRAND STYLE OF CIGARETTES THAT APPLICANT INTENDS TO SELL IN CALIFORNIA. ALSO SUBMIT, ON CD OR DVD, A COLOR PHOTOGRAPH IN ADOBE 6.0 (.PDF) SOFTWARE, OF THE PACKAGING AND LABELING. FOR EACH BRAND FAMILY, ATTACH COPIES OF YOUR WRITTEN CERTIFICATION OF COMPLIANCE WITH THE CALIFORNIA CIGARETTE FIRE SAFETY AND FIREFIGHTER PROTECTION ACT, WHICH YOU FILED WITH THE STATE FIRE MARSHAL. (HEALTH & SAF. CODE, § 14951, SUBD. (a).) FINALLY, SUBMIT A COMPLETED BRAND STYLE AUTHENTICATION INFORMATION FORM (JUS-TOB15) FOR EACH BRAND STYLE. 2. TRADEMARK HOLDER(S). (IF APPLICANT IS A PM, IT MAY SKIP QUESTION 2 AND GO DIRECTLY TO DECLARATION, ACKNOWLEDGEMENT AND SIGNATURE PAGE 12.) PROVIDE THE NAME, ADDRESS AND PHONE NUMBER OF THE TRADEMARK HOLDER(S) OF EACH BRAND LISTED ABOVE. TRADEMARK HOLDER AND CONTACT PERSON BRAND PHYSICAL ADDRESS PHONE ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE. 1. PART III: ATTACH ORGANIZATIONAL DOCUMENTS (SEE INSTRUCTIONS FOR LIST OF DOCUMENTS REQUIRED BY THIS QUESTION). ADDITIONAL BUSINESS INFORMATION 2. COMPANY OFFICERS AND OWNERS. COMPLETE THE TABLE BY LISTING ALL COMPANY OFFICERS AND COMPANY OWNERS (ALL PERSONS WITH AN EQUITY INTEREST OF 10% OR MORE IN APPLICANT COMPANY). ATTACH ADDITIONAL SHEET(S), AS NEEDED, TO PROVIDE A COMPLETE RESPONSE. PRESIDENT 1. CHECK APPROPRIATE OTHER TITLE PARTNER VICE PRES. OTHER PARTNER SECRETARY OTHER PARTNER TREASURER OTHER PARTNER 2. FULL NAME (first, mid. last) 3. STREET ADDRESS 4. TELEPHONE # FACSIMILE # 5. DATE & PLACE OF BIRTH 6. E-MAIL ADDRESS American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA JUS-