2019 Tobacco Directory Application Initial Supplemental Renewal Part I: GENERAL BUSINESS AND OWNERSHIP INFORMATION 1. Applicant Tobacco Product Manufacturer Identification Applicant Physical Address of Manufacturing Plant: Mailing Address: Phone Number: Facsimile Number E-Mail Address Name/Title of Person Completing Certification: 2. The undersigned certifies that as of the date of this Certification, the above-named applicant is a: (MUST Initial One) Participating Manufacturer ("PM") and has generally performed its financial obligations under the Master Settlement Agreement (See Instructions). Nonparticipating Tobacco Product Manufacturer ("NPM") in full compliance with 37 O.S. 247247600.21 - 600.23, having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales, including any quarterly deposits the applicant was notified it was required to make. OKLAHOMA ATTORNEY GENERAL - TOBACCO ENFORCEMENT UNIT American LegalNet, Inc. www.FormsWorkFlow.com a. If the Applicant was notified by any State that it was required to place funds into Escrow and the Applicant did not timely do so and/or was de-listed by any State, provide a full explanation for each failure to timely deposit. b. Is Applicant located outside the United States? Yes No 3. Applicant is the actual 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 and has been for the entire eighteen month period preceding this Directory application. 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. A Company other than Applicant manufactured any of Applicant's cigarettes during any time in the eighteen months that precede the date this Directory application. Yes No If the answer is "Yes," identify each cigarette manufacturer (i.e., fabricator), its manufacturing plant street address, business office mailing address, contact person, telephone and facsimile phone numbers, and the relationship to Applicant, if any. Provide a copy of every agreement or contract between applicant and the fabricator. 5. Applicant manufactured cigarettes on behalf of another manufacturer during anytime during the eighteen months that preceded the date of this application. Yes No If the answer is "Yes," identify each cigarette by brand and manufacturer, its street address, mailing address, contact person, telephone and facsimile phone numbers, and the relationship to Applicant, if any. Provide a copy of every agreement or contract between applicant and the manufacturer for whom you manufactured cigarettes. 6. Applicant is the first purchaser for resale in the United States of cigarettes manufactured anywhere. Yes No American LegalNet, Inc. www.FormsWorkFlow.com If the answer is "Yes," identify each cigarette manufacturer (i.e., fabricator), its manufacturing plant 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. 7. INDIAN TRIBE/NATION AFFILIATION A. Is Applicant a Federally Recognized Indian Tribe/Nation or a Legal Entity formed under Tribal Law? Yes No B. Is Applicant owned by a Member(s) of an Indian Tribe/Nation and located on Tribal Land? Yes No C. Is there any financial relationship between the Applicant and an Indian Tribe/Nation upon whose land the applicant is located? Yes No D. Does an Indian Tribe/Nation upon whose land the applicant is located manage or exercise any control over the applicant? Yes No E. Does the Indian/Tribe Nation upon whose land the applicant is located hold any ownership interest in the applicant? Yes No F. Does Applicant have or make any claim of Tribal Sovereign Immunity? Yes No If your answer to any of these questions is 223Yes,224 please provide the information requested below and contact the Oklahoma Office of the Attorney General, Tobacco Enforcement, to make arrangements to execute required waivers of Sovereign Immunity in order to appear on the Oklahoma Tobacco Product Manufacturers Directory. (See Instructions). Full Name of Tribe: Mailing Address of Tribal Headquarters: Telephone Number for Tribal Headquarters: American LegalNet, Inc. www.FormsWorkFlow.com 8. Licenses/Permits a. Oklahoma Tax Commission (OTC) Permit number(s): Attach Copies of all current and valid licenses from the Oklahoma Tax Commission (OTC). 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 thereunder. c. Federal Taxpayer ID Number: d. 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 takes place. PART II: BRAND FAMILY IDENTIFICATION 9. Brand Family Identification A. Brand Family Will this brand family be sold in 2019? Yes No B. Units Sold in Preceding Calendar Year: C. Manufacturer of Brands Listed (Include complete address information): If not previously submitted, or if the previously submitted packaging has changed, attach samples of the actual packaging and labeling for each brand of Cigarettes that applicant intends to sell in Oklahoma. Also submit on CD or DVD, a color photograph in PDF format, of the packaging and labeling. See Instructions. If you do not have additional Brand Family Identification to report, skip to number 10. American LegalNet, Inc. www.FormsWorkFlow.com A. Brand Family Will this brand family be sold in 2019? Yes No B. Units Sold in Preceding Calendar Year: C. Manufacturer of Brands Listed (Include complete address information): If not previously submitted, or if the previously submitted packaging has changed, attach samples of the actual packaging and labeling for each brand of Cigarettes that applicant intends to sell in Oklahoma. Also submit on CD or DVD, a color photograph in PDF format, of the packaging and labeling. See Instructions. 10. PACKAGING SAMPLES (check one) Initial or Supplemental Application: Samples of the actual packaging and labeling for each 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 has been no changes in the packaging. Please attach any packaging samples. 11. 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: 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, a copy of any agreement(s) for the use of the Trademark by the Applicant, and a Sworn Affidavit from the Trademark Holder confirming that no entity other than Applicant is authorized to manufacture the brand family(s) for which certification is requested. If you do not have additional Brand Family Identification to report, skip to number 12. American LegalNet, Inc. www.FormsWorkFlow.com 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: 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, a copy of any agreement(s) for the use of the Trademark by the Applicant, and a Sworn Affidavit from the Trademark Holder confirming that no entity other than Applicant is authorized to manufacture the brand family(s) for which certification is requested. PART III: BUSINESS ORGANIZATIONAL INFORMATION