STATE OF OKLAHOMA TOBACCO PRODUCT MANUFACTURER CERTIFICATION FOR LISTING ON OKLAHOMA DIRECTORY (68 O.S. §§ 360.1, et seq.) M ail this completed certification and all attachments to: Office of the Attorney General State of Oklahoma Tobacco Enforcement Unit 313 NE 21 st Street Oklahoma City, OK 73105 G Initial G Supplemental G Renewal PLEASE TYPE OR PRINT Sales Year: 2011 OAG-TOB1 (01/24/11) 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: (Please Initial One) G a Participating Manufacturer (“PM”) and has generally performed its financial obligations under the Master Settlement Agreement. (See Instructions) G a Nonparticipating Tobacco Product Manufacturer (“NPM ”) in full compliance with 37 O.S. §§ 600.21600.23, 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. 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. Attach additional sheet(s), as necessary, to provide a complete response b. Applicant is located outside the United States. G Yes G No If the answer above is yes, provide a declaration from each importer of your product into the United States, that such importer accepts joint and several liability with applicant for all escrow deposits due, for all penalties assessed and for payment of all costs and attorney fees imposed in accordance with sections 600.21 through 600.23 of Title 37 of the Oklahoma Statutes, with appointment for the declaration of a resident agent for service of process in Oklahoma. (Note: A Declaration of Importer Form OAG-TOB4-2009 can be found on our website). 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 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 through an importer. G Yes G 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. Attach additional sheet(s), as necessary, to provide a complete response. 4. A Company other than Applicant manufactured any of Applicant’s Cigarettes during any time in the previous year. G Yes G No If the answer is “Yes”, identify each Cigarette manufacturer (ie, fabricator), its plant 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 fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 5. Applicant is the first purchaser for resale in the United States of Cigarettes manufactured anywhere. G Yes G No If the answer is “Yes” , identify each Cigarette manufacturer (ie, fabricator), its plant street 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. Attach additional sheet(s), as necessary, to provide a complete response. 6. INDIAN TRIBE/NATION AFFILIATION Please answer the following questions by placing an “X” in the box marked yes or no after each question: A. Is applicant a Federally recognized Indian Tribe/Nation or a legal entity formed under tribal law? B. on Tribal land? C. G Yes G No Is applicant owned by a member(s) of an Indian Tribe/Nation and located Does applicant have or make any claim of Tribal sovereign immunity? G Yes G No G Yes G No If your answer to any of these questions is “Yes”, please provide the information requested below and contact the Oklahoma Office of the Attorney General, Tobacco Enforcement Unit, 313 NE 21st Street, Oklahoma City, OK 73015, to make arrangements to execute required waivers of sovereign im munity 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 Page 3 7. Licenses/Permits: a. 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 8. Brand Family Identification A. Brand Family Indicate those brands that will not be sold in 2011 with an asterisk (*) B. Units Sold in Preceding Calendar Year C. Manufacturer of Brands Listed Include complete address information Attach additional sheet(s), as necessary, to provide a complete response. 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 Adobe Acrobat (PDF) software, of the packing and labeling. See Instructions. 9. PACKAGING SAMPLES (check one) G Initial or Supplemental application: Samples of the actual packaging and labeling for each brand (without tobacco) are attached. G 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. 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 Attach additional sheet(s), as necessary, to provide a 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, 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 manufacturer the brand family(s) for which certification is requested. PART III: BUSINESS ORGANIZATIONAL INFORMATION 11. Organizational Documents to Be Attached (See Instructions for list of documents required by this question) American LegalNet, Inc. www.FormsWorkFlow.com Page 4 12. ARTICLES OF INCORPORATION & BYLAW S (if this is a renewal application check one) G G 13. 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. Company Officers & Owners Complete the table by listing all company officers and company owners (all Persons with an equity interest of 10% or more in applicant company.) 9 President 9 Partner 9 Other_____________ 1. CHECK APPROPRIATE TITLE 9 Vice Pres. 9 Partner 9 Other______________ 9 Secretary 9 Partner 9 Other _____________ 9 Treasurer 9 Partner 9 Other _____________ 2. Full Name 3. Street Address 4. Telephone # Facsimile # 5. Date and place of birth 6. E-mail address Attach additional sheet(s), as needed, to provide a complete response. PART IV: MARKETING AND DISTRIBUTION INFORMATION 14. Fire Safe Cigarettes G Yes G Are the brand families you manufacture certified as Fire Safe Cigarettes in Oklahoma? No If your answer is “YES”, on a separate sheet, please list all brand families and styles certified as Fire Safe Compliant in Oklahoma, and provide a copy of the current certification by the Oklahoma State Fire Marshal. NOTE: All Manufacturers that sell cigarettes in Oklahoma must be in compliance with the Fire Safety Standard and Firefighter Protection Act, codified at Title 74 O.S. Section 326.1 ("Fire Safe Cigarettes). The certifications under this Act must be made to the Oklahoma State Fire Marshal's office. The Oklahoma Fire Safe directory of all cigarettes certified under this Act can be found at: www.firemar.state.ok.us 15. Prevent All Cigarette Trafficking Act (PACT Act) a. Has applicant registered as a tobacco manufacturer with the Oklahoma Tax Commission? G Yes G No (Provide a copy of your current manufacturer’s registration with the OTC.) b. Has applicant filed monthly reports of all shipments of cigarettes and tobacco products into Oklahoma during the previous calendar year with the Oklahoma Tax Commission? G Yes G No (Provide a copy of your monthly shipment reports filed with the OTC.) 16. Stamping Agents For each brand that applicant intends to sell, list the name and address of every Oklahoma Stamping Agent that purchased or handled any of applicant’s gross Cigarette or RYO sales for that brand family in Oklahoma in the last calendar year. American LegalNet, Inc. www.FormsWorkFlow.com Page 5 STAMPING AGENTS Brand Family Stamping Agent Address Phone Number Attach additional sheet(s), as necessary, to provide a complete response. If the information requested is included in applicant’s monthly shipment reports to the OTC, check the box below and proceed to the next question. G The information requested is contained in the monthly shipment reports filed with the OTC and the OAG. ____________________________________________________________________________________ PART V. MANUFACTURING AND COMPLIANCE INFORMATION 17. 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 For each brand, attach the Federal Trade Commission’s current written approval of applicant’s annual Cigarette Health Warning rotation plan. Attach additional sheet(s), as necessary, to provide a complete response. 18. 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 Submitter Street Address Attach copies of all current certificates of compliance received from the U.S. Health and Human Services for applicant’s annual ingredient reporting required by the Federal Cigarette Labeling and Advertising Act. (15 U.S.C. § 1335a). Attach additional sheet(s), as necessary, to provide a complete response. 19. Convictions Has applicant or any Person or Affiliate listed in applicant’s responses to Part II, questions (4) or (10) or Part III, question (13) been convicted or entered a guilty plea to any crime under federal, state or foreign laws in connection with the sale of Cigarettes? For every such plea or conviction, list: (a) the name of the applicant or other Person or Affiliate convicted or entering a guilty plea; (b) the governmental entity (federal, state, local or foreign) that prosecuted applicant or other Person or Affiliate; (c) the case number; (d) the name and address of the government attorney or official that prosecuted applicant or other Person or Affiliate. G Yes, the details of each occurrence are attached to this Certification. G Not Applicable American LegalNet, Inc. www.FormsWorkFlow.com Page 6 PART VI: NPM APPLICANT CERTIFICATION If applicant is a PM, it may skip Part VI and go directly to Part VII, page 13. 20. AGENT FOR SERVICE OF PROCESS Please answer the following questions by placing an "X" in the box marked yes or no after each question: a. b. G Yes G No Is applicant domiciled in the State of Oklahoma? Is applicant a non-resident or foreign NPM that has registered to do business in Oklahoma as a foreign G Yes G No corporation or business entity? c. 21. If applicant answered “no” to questions “a” and “b” above, applicant must appoint a resident agent for service of process by submitting a completed NOTICE OF APPOINTMENT OF REGISTERED AGENT AND REGISTERED AGENT’S STATEMENT (OAG-TOB2). QUALIFIED ESCROW FUND-FINANCIAL INSTITUTION Please indicate whether the following statements describe applicant by marking either yes or no after the statement: Applicant certifies that of the date of this Certification, applicant: G Yes G No a. Has established and continues to maintain a Qualified Escrow Fund. b. Has executed a Qualified Escrow Agreement that has been reviewed and approved by the Attorney General for the State of Oklahoma and that governs that Qualified Escrow Fund for the State of Oklahoma. G Yes G No c. An amendment(s) to the applicant’s escrow agreement was executed in the past calender year. G Yes G No d. Has submitted a copy of the current escrow agreement and any amendments to it. e. Has submitted written confirmation from the Escrow Agent stating the amount of funds in G Yes G No G Yes G No escrow. Note: Oklahoma’s Escrow Agreement is available on the Attorney General’s website at: http://www.oag.ok.gov/oagweb.nsf/tobacco.html 22. QUALIFIED ESCROW FUND DEPOSIT/W ITHDRAW AL HISTORY FOR OKLAHOMA DATE DEPOSIT W ITHDRAW AL BALANCE Attach additional sheet(s), as necessary, to provide a complete response. PART VII: CERTIFICATION FEE 23. Effective January 1, 2010, Section 360.4 (A) (10) of Title 68 provides that “At the time a manufacturer submits a yearly written certification pursuant to this section, the manufacturer shall pay to the Office of the Attorney General a fee of One Thousand Dollars ($1,000.00).” Is your payment included with this certification application? G Yes G No American LegalNet, Inc. www.FormsWorkFlow.com Page 7 $ NOTE: This Certification will not be processed or considered by the Attorney General’s Office until all the required documents are submitted. Incomplete and/or illegible Certifications will not be processed. DECLARATION, ACKNOWLEDGMENT AND SIGNATURE Under penalty of criminal prosecution under the laws of Oklahoma, I declare and acknowledge that: 1. I have read the Instructions for this Certification for Listing on Oklahoma Directory. 2. I understand that the Attorney General may require additional information and/or documentation to determine if applicant is qualifies for listing on the Oklahoma Directory. 3. Applicant will immediately notify the Tobacco Enforcement Unit in the Attorney General’s Office (Office of the Attorney General for the State of Oklahoma, Tobacco Enforcement Unit, 313 NE 21 st Street, Oklahoma City, OK 73105) 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 Oklahoma 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 68 O.S. §§ 360.1, et seq., or 37 O.S. §§ 600.21-600.23 and any rules promulgated pursuant to these statutes, may be commenced against Applicant in any state court within Oklahoma, that the laws of the State of Oklahoma will govern such proceedings, and that Applicant waives any immunity from suit, liability, judgment and collection that Applicant may possess. 6. I have exam ined this Certification, including 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: Telephone:______________________________ E-mail address:____________________________________________ Signature of Authorized Officer: Date: STATE OF COUNTY OF COUNTRY OF ) ) ) Subscribed and sworn to before me this day of , 2011, 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. Notary Public My Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com