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Non Participating Manufacturer Certification Form. This is a Pennsylvania form and can be use in Office Of Attorney General Statewide.
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Tags: Non Participating Manufacturer Certification Form, Pennsylvania Statewide, Office Of Attorney General
TES - 006 (2/19) Page 1 of 16 Incomplete or illegible certifications will not be processed Complete all fields or indicate N/A 226 Do not leave blanks. Please review all instructions for further information. Failure to provide all necessary information will result in the rejection of your certification. PART I: Tobacco Product Manufacturer Identification Company Name Address City State Zip Code Country Telephone Number Fax Number Factory Address (use additional sheets if necessary) Name of Designated Contact Name of Legal Counsel for cc (optional) Email Address Designated to Accept All Official Communication Legal Counsel Email Address Company Website Address Manufacturer222s Federal Taxpayer ID# Name of Importer Importer222s Address Importer222s Federal Taxpayer ID# US Customs ID# This Form is (check one): Annual Certification (due between April 15 and April 30 for Pennsylvania sales in the previous year) Supplemental Certification (changes to information on previously submitted forms) Initial Certification (Manufacturer not currently listed on Pennsylvania222s directory) Initial Certifications will require additional documentation. American LegalNet, Inc. www.FormsWorkFlow.com TES - 006 (2/19) Page 2 of 16 Incomplete or illegible certifications will not be processed PART II: General Questions for the Manufacturer (attach additional sheets if necessary) 1. Are you the actual manufacturer (i.e. fabricator) of the brands listed in this certification? Yes No If 223No,224 please explain your reason for certifying. 2. Are you the Trademark Owner of the brands listed in this certification? Yes If 223Yes224 attach a copy of your live trademark from the USPTO website. No If 223No224 provide the name and contact information of the owner, attach a copy of the live trademark from the USPTO website and a copy of any agreement that defines trademark rights and/or control over the manufacturing of the cigarettes (such as an exclusive manufacturing agreement) and attach an executed copy of such agreement. Live Trademark Attached Executed Agreement Attached 3. Attached a copy of the Federal Trade Commission (FTC) approval letter for the current year for all brands listed in this certification? Yes No If 223No,224 please explain why it is not available. 4. Attached a copy of the U.S. Centers for Disease Control (CDC) ingredient listing compliance letter for the current year for all of the brands listed in this certification? Yes No N/A If 223No,224 please explain why it is not available. 5. Have you ever had an enforcement action taken against you that you have not previously disclosed to this Office? Yes No If 223Yes,224 list the state(s) involved, date and a detailed explanation. (Attach additional sheets if necessary.) If you have previously supplied information on these types of actions, please list year of disclosure. 6. Have you ever been denied Directory Listing in any other state or commonwealth that you have not previously disclosed to this Office? Yes No If 223Yes,224 list the state(s) involved, date and a detailed explanation. (Attach additional sheets if necessary.) If you have previously supplied information on these types of actions, please list year of disclosure. 7. Attached a copy of the PA Department of Revenue222s Cigarette Manufacturer Certificate for fire safe cigarettes and corresponding laboratory test results? Yes No N/A If 223No,224 please explain why it is not available. American LegalNet, Inc. www.FormsWorkFlow.com TES - 006 (2/19) Page 3 of 16 Incomplete or illegible certifications will not be processed 8. Attached a copy of the Pennsylvania Tobacco Products License (RYO). Yes No N/A If 223No,224 please explain why it is not available. 9. Is the responsible party current with their monthly report filings to the PA Department of Revenue in accordance with the federal Prevent All Cigarette Trafficking Act/Jenkins Act 15 U.S.C 247 375 226 378? For verification purposes, please provide all monthly Pact Act reports from the prior calendar year listing shipments of any of your tobacco products into Pennsylvania regardless of the entity who filed the Pact Act Reports. Yes No If 223No224 please explain. 10. Is a copy of your current qualified escrow agreement on file with our office? Yes No If 223No,224 please attach a copy of a new qualified agreement which has been approved by this office. 11. CSA/Distributor - New Non-Participating Manufacturers must secure a CSA/Distributor and initiate sales within six (6) months of Directory Listing. Failure to do so will result in removal from the PA Directory. Name of Distributor 12. Are any of your brand styles, contained in this certification, currently under review or been issued a Non-Substantial Equivalence Order or otherwise recalled by the FDA within the past two (2) years? Yes No If 223Yes224 provide the FDA documentation regarding the Non-Substantial Equivalence Order or recall for all brand style and a detailed explanation. If 223No224 provide the completed notarized affidavit located at the end of this form stating all certifying brands/styles are current and in compliance with FDA rules and regulations. For any newly added brand style(s) please provide documentation to establish the style(s) in compliance with the Family Smoking Prevention and Tobacco Control Act and all regulations promulgated thereunder, and therefore able to be sold legally in the United States. Should a brand style be determined to be Non-Substantially Equivalent or otherwise recalled by the FDA throughout the course of the year, you are required to provide information as soon as it is made available to ensure that products on the Directory remain legal for sale. 13. Have your manufacturing facilities changed locations within the last certification year? Yes No If 223Yes224 provide an address of this facility as well as photos and diagram of the manufacturing facility. INITIAL CERTIFICATIONS ONLY (Annual Certifications check N/A) American LegalNet, Inc. www.FormsWorkFlow.com TES - 006 (2/19) Page 4 of 16 Incomplete or illegible certifications will not be processed 1. Attached a photograph and diagram of the manufacturing facility? Yes No N/A If 223No,224 please explain why it is not available. 2. Attached a copy of the company222s organizational chart? Yes No N/A If 223No,224 please explain why it is not available. List all officers/owners of the applicant. Attach additional sheets if necessary. Name & Title Address Telephone Number Email Address 3. Do you have any parent, subsidiary sister or other affiliated entities? Yes No If 223Yes224 list all such entities, their relationship and whether they manufacture, sell or distribute tobacco products for sale in PA. Attach additional sheets if necessary. Company Name and Address Contact Person and Telephone Number Does this Company Sell or Distribute Tobacco Products for Sale in PA PART III: Brand Family Identification (attach additional sheets if necessary) Provide an electronic color copy of every brand style or promotional packaging. Include views of each side of the packaging with UPC clearly visible. American LegalNet, Inc. www.FormsWorkFlow.com TES - 006 (2/19) Page 5 of 16 Incomplete or illegible certifications will not be processed Section A. Brands Currently Certified and on the Directory (required on Annual Certifications only) List brands and styles that will remain on the Directory Brand Style/Flavor Filter/Non Package Cigarette/RYO Indicate with an asterisk(*) any brands previously sold that are not being sold in the current year. Section B. Brands to be Removed from the Directory List brands and styles currently on the Directory that will no longer be certified. Brand Style/Flavor Filter/Non Package Cigarette/RYO Section C. Additional Brands to be Certified List additional brands and styles to be added to the Directory. List the Brand and Stamping Agent. If a brand family has been manufactured by more than one manufacturer, on a separate sheet of paper provide the name and address of every other tobacco product manufacturer and the dates the brand was produced by each manufacturer. Brand Style/Flavor Filter/Non Package Cigarette/RYO Brand Cigarette/