OFFICE OF THE ATTORNEY GENERAL Lawrence G. Wasden Consumer Protection Division 954 W. Jefferson, 2nd Floor P.O. Box 83720 Boise, ID 83720-0010 Phone: (208) 334-2424 For Office Use Only NON-PARTICIPATING MANUFACTURER'S (NPM) APPOINTMENT OF REGISTERED AGENT FOR STATE OF IDAHO AND REGISTERED AGENT'S STATEMENT NON-PARTICIPATING TOBACCO MANUFACTURERS: The undersigned Non-Participating Manufacturer ("NPM") ___________________________________________ hereby appoints _________________________________________________ as its registered agent to receive service of process on its behalf. NPM agrees to do the following: (1) provide notice to the Office of the Attorney General for the State of Idaho ("Attorney General") at least thirty (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 (5) calendar days prior to the termination of an existing agent appointment. NPM further agrees that if the agent terminates its agency appointment, NPM shall provide notice to the Attorney General of the termination within five (5) 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 attachments, if any, are true, correct, accurate and complete in every particular, and that I am a person authorized, either under the laws of the State of Idaho or of the jurisdiction where the manufacturer resides or is organized, to bind the NPM making this Certification. Any violation of the requirements of Idaho Code § 39-8404 is a basis for removal of the NPM and its Brand Families from the Idaho Directory of Compliant Tobacco Product Manufacturers and Brand Families. ** This Appointment must be signed and dated before a notary public ** Signature of NPM or NPM's Authorized Designee: ________________________________________________________ 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 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'S APPOINTMENT OF REGISTERED AGENT Page 1 of 2 (revised 1/6/2015) American LegalNet, Inc. www.FormsWorkFlow.com NAME AND ADDRESS OF IDAHO STATE REGISTERED AGENT: Name: ____________________________________________________________________________________________ Street Address (Required ­ Must be within Idaho): ________________________________________________________ P. O. Box (Optional ­ Must be in same city as street address): ________________________________________________ City & State: _________________________________________ Telephone: _______________ FAX: ___________________ Zip Code: ___________________________________ Email: _____________________________________ I consent to serve as Registered Agent in the State of Idaho for the NPM named herein, pursuant to Idaho Code § 39-8404. 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 Appointment must be signed and dated before a notary public ** Registered Agent Signature: _____________________________________________ Date: _____________________ Registered Agent Printed 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 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'S APPOINTMENT OF REGISTERED AGENT Page 2 of 2 (revised 1/6/2015) American LegalNet, Inc. www.FormsWorkFlow.com