" State of New Jersey NPM-A Non-Participating Manufacturer Certification of Appointment of Agent for Service of Process Please Rc\'íew liistructions Prior to Completion Certification Part 1: Certfication Year and Type of Certifi catÍ on Year: Complete a separate fomi for each certification year for \vhich YOll arc certifying. 201 1 ccriiiication year is for20iu sales (check one) D Type of Certification: (check one) Initial D D 2011 Annual D D Other: Supplemenial Part 2: Manufacturer Identifcation Company Name Mailing Address City I Zip Cndc I Slaie Phone I Country I Fax I FEIN Name and Title of Person Completing this Form Email Adåæss Part 3: Manufacturer Status (Check one) o 'niC NPl'..1 ccnilies thai it is registered!O do business in New Jersey. (Attach certifcation/rom New Jersey Secretary oISln/e.) o The NPM certifies that it is a non~rcs¡dcnt or foreign NPM that has not regisicn:-d to do business in New Jersey, and hereby certifies ¡hat it has appointed an agent, located within the State of New Jersey, to receive service of process on its behalf (Complete Part 4 amI auacl, proof of appoitulteii aiid aiiailabilo' of Agem.) Company Physical Address City State Zip Code City State Zip Code Phone Fax E-Mail Maìling Address Availability of Agent (hours of business) Part 5: Manufacturer Certifcation Under penalties of perjury, I state that, to the best of my knowledge, all of the info0113tion contained in this Certification and any attached dociiiieiis arc true and accurate. This doculleii must be s(r./ted aiid dated by aii authorized 110tal)' public. NPM Authorized Designee (Pnnt Name) Title Signature of NPM Authorized Designee Date Subscribed and swam to before me this dale: Signaiure ofNot~-uy Public Coiiniy . Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey NPM-A Non-Participating Manufacturer Ccrtilcation of Appointment of Agent for Service of Process Instructions Specific Instructions General Information Who must fie this Certifcation'! Part 1: Certification Year and Type of Certification Any Non-Participating Manufacturer (NPM) whose cigarettes or roll-your-own tobacco (RYO) were sold in New Jersey . Mark appropriate certification year. You must submít a during the preceding calendar year or who intends for its brands to be listed as compliant in the New Jersey Directory of Compliant NPMs. separate ceitification for each year you are certifying. If "Other" is checked, enter certification year for which certification is being provided. Mark whether this is an initial (manufacturer is not currently listed on the New Jersey Direetory), annual (due April 15, 20 i 1 Who Mnst Appoint an Agent for Service of for 20 i 0 sales) or supplemental (change of infonnation Process'! provided to the Attorney General) certification. . Non-resident (out-or-state) and foreign NPMs who are not registered to do business in New Jersey arc required to continually engage, \vithout inten"uption, an agent in this State for acceptance of service of process. Where an NPM's produets are sold in New Jersey and the NPM fails to appoint an agent as required by N.J.S.A. 52:4D-I £1. ~., the NPM shall be deemed to appoint the New Jersey Secretary of State as the agent on whom process may be served on its behalf However, such appointment wil not satisfy the condition precedent for having its brand families lìsted in the Directory of Compliant NPMs. When is this Certification due'! The annual certification must be tiled with the Anorney General no later than April 15 of each year for the preceding year's sales. An initial certif1cation may be filed at any time, Updates an agent, the NPM shall notify the Attorney General at least 30 calendar days prior to the temiination and provide proof of the appointment of a new If the NPM tern1inates the authority of agent at least 5 calendar days prior to the tem1Ínation. If the agent terminates an agency appointment, the NPM shall notify the Attorney General of the termination \vithin 5 calendar days of the termination and shall include proof of ùie appointment of a new agent For Additional Information Phone DAG Glenn T. Graham at (973) 648-7457 Part 2: Mannfacturer Identification Provide your company name, address, and phone, fax, FEIN numbers, person fillng out certification and email. Part 3: Mannfacturer Statns . rf you are registered to do business in New Jersey, A TT ACH CERTIFICATION FROM NEW JERSEY DIVISION OF REVENUE, BUSINESS REGISTRATION and complete Part 5. rfyou are not registered to do business in New Jersey you must appoint an agent for service of process who Is located within New Jersey. ATTACH CURRENT PROOF OF APPOINTMENT AND AVAILABILITY OF AGENT. Part 4: Agent Appointed for Service of Process . Provide contact name and company of Agent appointed for process. Provide their physical (street) address as well as mailng address, phone and fàx numbers, e-mail address and availability. service of Availabilty of Agent: normal business hours during which the agent is available at the address provided for the puipose of service of process, Part 5: Mannfactnrer Certification The authorized designee executing the certification must be an officer, principal, director or other authorized representative of the manufacturer. The authorized desIgnee's name and title must be legibly printed and thc signaturc must bc notarized. Mail original document, with attachments to: or visit: New Jersey Offce of the Attorney General Division of Law http;llwww.nj.gov/oag/oag_tobacco.htmI 124 Halsey Street P.O. Box 45029 Newark, New Jersey 07101 ATTN: DAG Glenn T. Graham American LegalNet, Inc. www.FormsWorkFlow.com Rev.2//0í20J/