STATE OF OKLAHOMA Declaration of Tobacco Product Importer Accepting Joint and Several Liability with NonParticipating Manufacturer for Escrow Compliance in Oklahoma And Appointing Resident Agent for Service of Process This Declaration must be executed by an officer of the Importer with authority to bind the Importer to the requirements of Oklahoma law as stated below. Execution of this Declaration is an assertion that all information provided is true and correct, and that the Importer accepts and agrees to all the terms specified below. 1. Tobacco Product Importer Identification Company's Full Legal Name: ______________________________________________________________________________ Type of Business Entity (check one): G Sole Proprietorship G General Partnership G Limited Partnership G Corporation G Limited Liability Company G Other (specify): __________________________________________________________ State/Country where Created, Incorporated or Registered:______________________________ Include with Declaration: · A copy of the current Articles of Incorporation, Certificate of Limited Partnership, Articles of Organization, or comparable applicable document, including any amendments, must be attached to the declaration. A copy of the Importer's current Tobacco Importer's Permit issued by the United States Alcohol and Tobacco Trade Bureau, with any amendments. · Trading As (list all names ever used): ______________________________________________________________________________ Federal Employers Identification Number: ______________________________________________________________________________ Federal Tobacco Importer Permit Number: ______________________________________________________________________________ Physical Address: ______________________________________________________________________________ Mailing Address: ______________________________________________________________________________ Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Company Phone: ______________________________________________________________________________ Contact: ______________________________________________________________________________ Title: ______________________________________________________________________________ Phone: ________________________________ Facsimile: ______________________________ Email: ____________________________________ Website: ____________________________ Name, Title and Dates of Service for all Current and Past Officers, Directors and/or Partners: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If the Tobacco Product Importer is represented by outside counsel for the purpose of compliance with 68 O.S. §360.5-1, provide the following information: Firm: ______________________________________________________________________________ Attorney: ______________________________________________________________________________ Address: ______________________________________________________________________________ Phone: ____________________________________ Facsimile: __________________________ Email: _______________________________________________________________________ 2. Importing Contract Information The Importer identified above imports into the United States cigarettes manufactured by: ______________________________________________________________________________ Tobacco Product Manufacturer's Name: _____________________________________________ ______________________________________________________________________________ The cigarette brands imported by the Importer for the Manufacturer identified above are as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The Importer imports these cigarettes under (check one): G G Written contract commencing ________________ and expiring ___________________. Oral contract or informal agreement. Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 3. Acceptance of Joint and Several Liability In accordance with 68 O.S. §360.5-1 of the Oklahoma statutes for all sales of the brands of cigarettes identified above which occur in Oklahoma, the Importer hereby accepts joint and several liability with the Tobacco Product Manufacturer, identified above for deposit of all escrow due, payment of all penalties imposed, and all costs and attorneys fees imposed in accordance with Sections 600.21 through 600.23 of Title 37 of the Oklahoma Statutes. This liability shall apply to such sales in Oklahoma commencing January 1st, and continuing until ninety days after written revocation of this acceptance is received in the Oklahoma Attorney General's Office. 4. Appointment of Resident Agent for Service of Process in Oklahoma The Importer appoints the resident agent in the State of Oklahoma identified below as its agent for the service of process on whom all process, and any action or proceeding against it concerning or arising out of the enforcement of Title 37 O.S. §600.21 through 600.23 may be served in any manner authorized by law: Agent: ______________________________________________________________________________ Company: ______________________________________________________________________________ Address: ______________________________________________________________________________ Phone: _____________________________ Facsimile: _________________________________ Email: _______________________________________________________________________ A Notice of Appointment of Registered Agent and Registered Agent Statement (OAGTOB6) Must be Attached to this Declaration. 5. Execution of Declaration I hereby affirm that all the information stated in this declaration is true and correct, and I hereby commit the Importer identified above to all the terms of this declaration. ________________________________ Signature _______________________________