STATE OF NEW MEXICO Tobacco Product Manufacturer Certification for Listing on New Mexico Directory Pursuant to NMSA §§ 6-4-14 to 6-4-24 Mail this completed certification and all attachments to: Office of the New Mexico Attorney General Attn: Tobacco Project (courier delivery address) 408 Galisteo Street Santa Fe, NM 8750 (U.S.P.S. delivery address) P. O. Drawer 1508 Santa Fe, NM 87504-1508 MARK ONE: Initial______________ Supplemental_______ Renewal____________ Are you requesting any new brands to be added this year?___________ SALES YEAR 2011 PART I: 1. TOBACCO` PRODUCT MANUFACTURER IDENTIFICATION (attach additional sheets if necessary to provide complete responses) Applicant Tobacco Product Manufacturer Identification Applicant:______________________________________________________________ Street Address:_________________________________________________________ City, State, Zip code_____________________________________________________ Mailing Address (if different from above)____________________________________ Phone Number:____________________ Facsimile (FAX) Number:_______________ E-Mail Address:_________________________________________________________ Website Address:________________________________________________________ Page 1 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com Name/Title of Person Completing Certification:_______________________________ Manufacturing Plant(s) Name and Street Address (if different from above) ______ Manufacturing Plant Phone Number:________________________________________ Manufacturing Plant Facsimile (FAX) Number________________________________ Name/Title/Phone Number of Person at Plant if different from above:____________ Please attach a photograph(s) and a diagram(s) of your manufacturing facility and indicate on the diagram(s) where the equipment and facilities for manufacturing (i.e., fabricating) the tobacco product(s) are located. 2. The undersigned certifies that as of the date of this Certification, the above-named applicant is: (initial one): _____ A Participating Manufacturer (“PM") under the Tobacco Master Settlement Agreement ______ a Nonparticipating Tobacco Product Manufacturer (“NPM”) in full compliance with New Mexico Statutes having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales, including any quarter deposits the applicant was notified it was required to make. If the applicant was notified by the New Mexico Attorney General that it is required to place funds into escrow and the applicant did not timely do so, provide a full explanation for each failure to timely deposit. 3. Applicant is the manufacturer (i.e. fabricator) of the brands listed on 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 If your answer is “no”, identify the name and address of the fabricator and state fully the applicant’s basis for seeking to have the brand(s) included in the directory. ______________________________________________________________________ ______________________________________________________________________ 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 Page 2 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com 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. _____________________________________________________________________________ 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 in NMSA 1978, § 6-4-12 I. 7. Indian Tribe Affiliation Please answer the following questions by marking yes or no after each question. Is applicant an Indian Tribe? _____ yes _____ no Is applicant a federally recognized Indian Tribe? _____ yes _____ no Is applicant a corporation formed under Tribal Law? _____ yes _____ no Is applicant affiliated with an Indian Tribe? _____ yes _____ no Is applicant owned by members of an Indian Tribe? _____ yes _____ no Does applicant have a facility or business premises Located on Tribal land? _____ yes _____ no Does applicant have or make a claim of Tribal Sovereign immunity? _____ no _____ yes If your answer to any of these questions is “yes”, you must provide the information requested below and contact the New Mexico Attorney General’s Office, 408 Galisteo St., Santa Fe, NM 87501, to make arrangements to execute required waivers of sovereign immunity in order to appear on the New Mexico Attorney General’s Directory. __________________________________________________________________________ Full Name of Tribe Mailing Address of Tribal Headquarters Telephone Number for Tribal Headquarters 8. Licenses/Permits: a. New Mexico Department of Taxation and Revenue License Number (as a manufacturer or importer)_______________ Page 3 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com Please list any additional licenses obtained from the New Mexico Department of Taxation and Revenue and their numbers?_______________________________ Attach copies of all current and valid licenses from the New Mexico Department of Taxation and Revenue. b. U.S. Treasury Tobacco Tax Bureau (TTB) Permit Number as a manufacturer: _______________________ and/or as an importer:______________________. Attach a copy of applicant’s current permit as a manufacturer or importer pursuant to 26 USC Chapter 52, and regulations issued there under. c. d. Applicant is compliant with the requirements of the New Mexico Fire Marshal’s Office and has completed the Cigarette Fire Safety Form for each brand listed. Further, Applicant has received permission from the New Mexico Fire Marshal that the brands are compliant. Evidence of compliance is attached e. Applicant has registered with Bureau of Alcohol, Tobacco, Firearms and Explosives under the “Prevent All Cigarette Trafficking (PACT) Act, and a completed copy of ATF Form 5070.1 is attached hereto. f. PART II: 9. If applicant is a manufacturer located in a country other than the U.S.A., provide copies of any Tobacco Manufacturer’s License/Certificate/Permit or similar document(s), or an Importer’s License/Certificate/Permit or similar document(s) issued by the country where the manufacturing occurs. Applicant has registered with the New Mexico Taxation and Revenue Department under the “Prevent All Cigarette Trafficking (PACT) Act and has filed monthly reports as required for all months since July 1, 2010 with the Taxation and Revenue Department and the New Mexico Attorney General BRAND FAMILY IDENTIFICATION (Attach additional sheets if necessary) Participating Manufacturers complete A & B; Non-Participating Manufacturers complete A through D. A. Brand Family B. Brand Name C. Units Sold in Preceding Calendar Year D. Manufacturer of Brands Listed (including complete address) Attach samples of the actual packaging and labeling for each brand of cigarettes that applicant intends to sell in New Mexico. Also submit on CD or DVD, a color photograph in Adobe Acrobat (.pdf) format, of the packing and labeling. Page 4 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com 9A. Packaging Samples (check one) ___ Initial Application: Samples of the actual packaging and labeling for each brand (without tobacco) are attached. ___ Supplemental Application: Samples of the actual packaging and labeling for each supplemental brand (without tobacco) are attached. ___ Renewal Application: Samples of packaging for all brands and products sought to be certified in the current year have been previously provided and there have been no changes in the packaging. ___ Renewal Application: Changes in the packaging of previously submitted samples have occurred and new packaging samples are attached. 10. Trademark Holder(s) Provide the name, address, and phone number of the trademark holder(s) of each brand listed above. Brand Trademark Holder and Contact Person Physical Address Phone Number Attach additional sheets as necessary to complete response. If the Trademark Holder of a listed brand is not the applicant, provide a complete explanation for the inclusion of the brand(s) in this application, and provide a copy of any agreement for the use of the Trademark by the applicant. PART III: ADDITIONAL BUSINESS INFORMATION 11. Organizational Documents to be Attached (See Instructions for list of documents required by this question) 11.A. Articles of Incorporation & Bylaws (if this is a renewal application check one.) _____ A copy of current articles of incorporation and bylaws have been submitted with the prior year certification. Those documents remain valid and current. _____ The articles of incorporation or bylaws have changed. Enclosed as Exhibit ___ Is a copy of the new articles and/or bylaws. 12. Company Officers & Owners: Complete the table by listing all company officers and company owners with an equity interest of 10% or more in applicant company. 1. Check title ___President ___Partner ___Other ___ V.P. ___ Partner ___ Other ___ Secretary ___ Partner ___ Other ___ Treasurer ___ Partner ___ Other 2. Full Name (first, middle, last) 3. Street Address 4. Telephone # Facsimile # Page 5 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com 5. 6. Date and Place of Birth E-mail address Attach additional sheets, as needed, to provide a complete response. 13. Affiliates Brand Family Affiliate: Name Type of Business Affiliate Street Address and Phone Number Attach additional sheets as needed to provide a complete response. IF APPLICANT IS A PM, SKIP THE REMAINDER OF PART III AND GO TO PART IV. 14. Applicant Information Please indicate whether the following statements describe applicant by marking either yes or no after each statement. a. Applicant sold Cigarettes in New Mexico in the preceding calendar year: ___ Yes ___ No b. Applicant made escrow deposits pursuant to NMSA 1978, § 6-4-13 ___ Yes ___ No c. Applicant sold in the preceding calendar year one or more of the brand families listed in this certification. ___ Yes ___ No d. Applicant made escrow deposits in the preceding calendar year pursuant to NMSA 1978, § 6-4-13 for one or more of the brand families listed in this certification. ___ Yes ___ No e. There has been a change in manufacturer (i.e. fabricator) of one or more of the brand families listed in this certification within the past two calendar years. ___ Yes ___ No f. Applicant advertises or sells cigarettes via the internet or in catalogs and uses the mail or other delivery service to deliver cigarettes to New Mexico consumers. ___ Yes ___ No g. Applicant failed to timely comply with any of the provision s of NMSA 1978, § 6-4-13 prior to the establishment of the Directory, or at any time thereafter. ___ Yes ___ No h. Applicant or one of its brand families listed on this certification was previously denied listing on the Directory or was removed from the Directory of this state or any other state.___ Yes ___ No i. Applicant is enjoined or banned from selling any cigarettes by court order, state or federal agency ruling or determination of this state or any other state. ___ Yes ___ No j. A brand family formerly sold by applicant or brand family that applicant intends to sell is enjoined from sale by a state court, state agency or a federal court. ___ Yes ___ No k. A state or federal court has entered a judgment finding that applicant engaged in an unfair business practice or unfair competition relating to the sale of tobacco products. ___ Yes ___ No l. Applicant sold more than 2,000,000 cigarettes in New Mexico during any quarter of 2009. ___ Yes ___ No m. Applicant failed to timely file any completed form or document required by NMSA 1978, § 6-4-13. ___ Yes ___ No PART IV. 15. MARKETING/DISTRIBUTION INFORMATION Tobacco Products Reclassified as Cigarettes or RYO Tobacco List all tobacco products sold by applicant that have been reclassified within the last two years as cigarettes or as roll-your own (RYO) tobacco by a federal agency, state or local government. Page 6 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com 16. Sales of Tobacco Product into New Mexico For each entity in New Mexico to whom your product was shipped, and for each entity outside of New Mexico to whom your product was shipped with knowledge that such product would be sold in New Mexico, please provide a written summary of the date and amount of each such shipment of product. 17. Stamping Distributors Brand Family 18. Participating Mfg. Address Name Phone Number Address Agreements Regarding Compliance with NMSA 1978, § 6-4-13. (see instructions) Brand Name PART V. 21. Phone Number Agreements Regarding Compliance with the MSA (see instructions) Brand Family 20. Address Agreements with Participating Manufacturers (see instructions) Brand Family 19. Stamping Distributor Address MANUFACTURING AND COMPLIANCE INFORMATION Manufacturer(s) For each brand family, list the name and address of the manufacturer (i.e., fabricator) of the Cigarettes, if other than applicant. Include all company names and addresses used by the manufacturer(s) in making cigarettes for sale in the United States. Brand 22. Manufacturer or fabricator Street Address Health Warning Rotation Plan (see instructions) For each Brand Family, list the name and address of the entity which filed a cigarette health warning rotation plan with the Federal Trade Commission before the cigarettes were distributed into the United States. Brand Entity that filed Street Address Page 7 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com 23. Ingredient Reporting (see instructions) For each Brand Family, list the name and address of the entity which submitted the ingredient reporting information to the U.S. Secretary of Health and Human Services as required by the Federal Cigarette Labeling and Advertising Act. Brand 24. Submitter Street Address Cigarette Packaging For each Brand Family, list the address of the person, company or entity that placed the cigarettes into packages with the U.S. Surgeon General’s warnings. Brand 25. Packager Street Address Internet or Mail Order Sales (see instructions) a. b. c. d. Websites:________________________________________________ Physical Address:__________________________________________ Total Internet Sales in New Mexico previous year:_________________ Does your company have a policy or protocol regarding the prevention of the sale of your tobacco products via the internet? ____ Yes, a copy of the policy or protocol is attached ____ No If your answer is “no”, please answer below: e. Have you filed any lawsuits against the owners or operators of any internet website that offers your products for sale to the public? ____Yes ____ No f. Have you sent any “cease and desist” letters to the owners or operators of any internet websites that offers your products for sale to the public? ____Yes ____ No g. Do you have trade policies in place that govern the remote sales of your tobacco products: ____ Yes ____ No h. If your answer is “yes”, have you entered into any agreement with merchants requiring them to agree to comply with your trade policies? ____ Yes ____ No Attach copies of the Jenkins Act reports filed with the New Mexico Department of Taxation and Revenue, as specified in the instructions. PART IV. DISCLOSURE OF ENFORCEMENT ACTIONS AND PRIOR DETERMINATIONS AFFECTING SALES TO DISTRIBUTORS (If applicant is a PM – it may skip this part and go directly to Part VII) 26. Enforcement Actions Banning or Enjoining Sales Has applicant or any person or affiliate listed in applicant’s responses to Part II, question 2 and Part III, questions 2, 3, and 4 had any of its cigarettes banned or enjoined from sale by any state or federal court or administrative agency within the United States jurisdiction? For each such action banning or enjoining sales, list: a. b. c. d. The brand family(ies) banned and/or enjoined; The governmental entity (federal, state, local or foreign) or private plaintiff bringing the action; The case number; The name and address of the government attorney or official or private plaintiff brining the action. ____ Yes, the details of each occurrence are attached to this Certification ____ not applicable Page 8 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com 27. Denials, Suspensions, Revocations of Permits or Licenses. Has applicant or any Person or Affiliate listed in applicant’s responses to Part II, question 2 and Part III, questions 2, 3 and 4 been denied a permit, license, or been denied any other authorization to engage in any business relating to the sale of cigarettes by any government entity (federal, state, local or foreign) or had such permit, license or other authorization revoked, suspended or otherwise terminated? For every such denial, suspension or revocation of a permit, license or other authorization, list: a. the name of the applicant or other person or affiliate that had such permit, license or other authorization revoked, suspended or otherwise terminated; b. the governmental entity (federal, state, local or foreign) that denied, suspended or revoked such permit, license or other authorization; c. the case number, if any; d. the name and address of the government attorney or official or private plaintiff bringing the action. ___ Yes, the details of each occurrence are attached to this Certification ____ Not applicable 28. Convictions Has applicant or any person or affiliate listed in applicant’s responses to Part II, question 2 and Part III, questions 2, 3 and 4, been convicted of any crime under federal, state or foreign laws in connection with the sale of cigarettes? For every such conviction, list: a. b. c. d. the name of the applicant or other person or affiliate convicted; the governmental entity (federal, state, local or foreign) that prosecuted applicant or other person or affiliate; the case number; the name and address of the government attorney or official that prosecuted applicant or other person or affiliate. ____Yes, the details of each occurrence are attached to this Certification 29. ___ not applicable Denial of Listing Has applicant or any person or affiliate listed in applicant’s responses to Part II, question 2 and Part III, questions 2, 3, and 4, been denied listing on any state directory, which is similar to the subject of this Certification? For every such denial, list: a. b. c. The name of the applicant or other person or affiliate denied listing on a state directory; The Tobacco Product Manufacturer and/or brand family(ies) denied listing; and The state which denied listing. ____Yes, the details of each occurrence are attached to this Certification 30. ___ not applicable Compliance with the Provisions of NMSA 1978, § 6-4-12, et seq. Has any person listed in applicant’s responses to part II, question 2 and Part III, questions 2, 3, and 4, been involved as an officer or owner of any other tobacco company or affiliate which has not made its escrow deposits as a Nonparticipating Manufacturer under a state reserve fund statute (or escrow statute)? For each such occurrence, list: a. b. c. the name of the applicant or other person or affiliate which has not satisfied its NPM reserve fund obligations; the brand families for which there was a failure to comply; and the amounts of any escrow deposits that are still owed. ____Yes, the details of each occurrence are attached to this Certification PART VII: 31. ___ not applicable IMPORTED CIGARETTES – DOCUMENT AND VERIFICATION U. S. Customs Documents Does the applicant sell or intend to sell cigarettes that are not made in the United States? ____Yes ____ No If applicant’s answer is “yes”, applicant MUST provide the documents listed below: a. A copy of the sworn statement of the original manufacturer that it will timely submit ingredients to the Secretary of Health and Human Services as required by 19 USC 1681a(c)(1). b. A copy of the importer’s certificate under penalty of perjury as required by 19 USC 168a(c) (2) regarding the precise format of warnings and the rotation plan for health warnings. Page 9 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com c. A copy of the trademark holder’s certificate under penalty of perjury that it has not withdrawn consent to import into the United States as required by 19 USC 1681a(c) (3) (A) OR a copy of the importer’s certificate under penalty of perjury that the trademark owner has not withdrawn consent to import into the United States as required by 19 USC 1681a(c) (3) (B). 32. Provide copies of U.S. Customs Form 7501s for all cigarettes sought to be listed by your company that were imported into the United States in the past calendar year and/or copies of all excise tax returns submitted to the Alcohol and Tobacco Tax and Trade Bureau during the past calendar year. 33. Provide copies of the invoices corresponding to the U.S. Customs form 7501 for any cigarettes manufactured by or for your company and imported into the United States in the past calendar year and invoices corresponding to excise tax returns submitted to the Alcohol and Tobacco Tax and Trade Bureau in the past calendar year for any of the tobacco products that you seek to have included in the Directory. 34. Provide a summary of the documents in Sub-parts 2 and 3 above reflecting a balance of the totals of the U.S. Customs form 7501s, the corresponding invoices and the excise taxes paid. PART VIII: NPM APPLICANT CERTIFICATION If applicant is a PM, it may skip Part VIII and go directly to DECLARATION, ACKNOWLEDGMENT AND SIGNATURE. 35. AGENT FOR SERVICE OF PROCESS Please answer the following questions by placing an “X” before yes or no after each question: a. Is applicant domiciled in the State of New Mexico? ____Yes ____ No b. c. 36. Is applicant a non-resident or foreign NPM that has registered to do business in New Mexico as a foreign corporation or business entity? ____ Yes ____ No If applicant answered “no” to questions “a” and “b” above, applicant must appoint a resident agent for service of process and that agent for service must directly notify the Attorney General of New Mexico in writing of that appointment. QUALIFIED ESCROW FUND-FINANCIAL INSTITUTION Please indicate whether the following statements describe applicant by placing an “X” before yes or no after each question. Applicant certifies that of the date of this Certification, applicant: a. Has established and continues to maintain a Qualified Escrow Fund ____ Yes ____ No b. Has executed a Qualified Escrow Agreement that has been reviewed and approved by the Attorney General for the State of New Mexico and that governs that Qualified Escrow Fund for the State of New Mexico. ____ Yes ____ No c. An amendment(s) to the applicant’s escrow agreement was executed in the past calendar year. (If answer is yes, please provide a complete copy of the amended escrow agreement). ____ Yes ____ No Please provide a written confirmation from the Escrow Agent stating the amount of funds in escrow. Note: The NPM must certify satisfaction of the above-referenced requirements regarding the Qualified Escrow Fund to be eligible for the Directory. New Mexico’s Escrow Agreement is available on the Attorney General’s website. 37. QUALIFIED ESCROW FUND DEPOSIT/WITHDRAWAL HISTORY FOR NEW MEXICO Date Deposit 38. Withdrawal Balance FIRE SAFER CIGARETTE REQUIREMENT COMMENCING JANUARY 1, 2010: I HEREBY ACKNOWLEDGE THAT I AM FAMILIAR WITH THE FIRE-SAFER CIGARETTE AND FIREFIGHTER PROTECTION ACT which becomes effective January 1, 2010 and that I have/will meet all requirements under that Act that are promulgated by the State Fire Marshal Division, Fire Code Enforcement Bureau of the State of New Mexico. Page 10 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION, ACKNOWLEDGMENT AND SIGNATURE Under penalty of perjury under the laws of New Mexico, I declare and acknowledge that: 1. I have read the Instructions for this Certification for Listing on New Mexico’s Directory. 2. I understand that the Attorney General may require additional information and/or documentation to determine if applicant is qualified for listing on the New Mexico Directory. 3. Applicant will immediately notify the New Mexico Attorney General’s Office, Tobacco Project at P. O. Drawer 1508, Santa Fe, NM 87504-1508, if any information on this certification changes, before the Attorney General approves the Certification. 4. I am an officer authorized to legally bind the above-named company either under the laws of the State of New Mexico or of the jurisdiction where the manufacturer resides or is organized. My position with the company and my actual authority to certify on behalf of applicant meets the foregoing requirements. 5. On behalf of the applicant, the undersigned agrees that any action or proceeding against it arising from enforcement of the provisions of NMSA 1978, §§ 6-4-12 – 6-424, and NMSA 1978, §§ 7-12-1 – 7-12-19 and any rules promulgated pursuant to these statutes, may be commenced against applicant in any state court within New Mexico, that the laws of the State of New Mexico will govern such proceedings, and that applicant waives any immunity from suit, liability, judgment and collection that applicant may possess. 6. I have examined this Certification, including all attachments and supporting documents, and to the best of my knowledge and belief, this Certification, including attachments and supporting documents, is true, correct, and complete. Name of Authorized Officer:__________________________________________ Title_____________________________________________________________ E-mail Address____________________________________________________ Telephone________________________________________________________ Signature of Authorized Officer____________________________ Date:________ STATE OF ____________) COUNTY OF __________) COUNTRY OF _________) On ___________________, be fore, ______________________________, personally appeared ____________________________________________, personally known to me (or proven to me on the basis if satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity, by his/her/their signature on the instrument the person or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal. Signature__________________________ Page 11 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com My commission expires_______________________ This Certification must be filed with the New Mexico Attorney General’s Office: New Mexico Attorney General 408 Galisteo St. Santa Fe, NM 87501 Attn: Tobacco Project Page 12 of 12 New Mexico 2011 Certification American LegalNet, Inc. www.FormsWorkFlow.com