State of Tennessee Certification Form for Listing on Tennessee’s Directory for 2011 Pursuant to Tenn. Code Ann. 67-4-2601 et. seq. Official Form 030711 Check appropriate response: ] Initial Directory Certification Application – Tobacco Product Manufacturer is not currently listed on the Tennessee Tobacco Directory. Attach Form 092809 NPM Bond Requirement. [ [ ] Supplemental Directory Certification – Change of information provided to the Attorney General and the Department of Revenue (change of information must be submitted at least 30 days prior to change or no more than 30 days after discovery of inaccurate, incomplete or misleading information.) Reason: _____________________________________________________________________________ ____________________________________________________________________________________ [ ] Annual Directory Certification – Due April 30 for continuation of listing on Tennessee’s Directory of Compliant Tobacco Product Manufacturers. Please type or legibly print in permanent blue ink. Use additional pages only when necessary. Part 1. General Information 1. Applicant Tobacco Product Manufacturer Identification. Applicant Name: Contact Person: Title: Street Address: City/State/Zip: Mailing Address if different from above: City/State/Zip: Telephone Number (include country code): Facsimile Number (include country code): E-Mail Address: Website Address: Name of Person Completing Certification: Title of Person Completing Certification: Important Note: The State will not process incomplete, unsigned or illegible certifications. Only official State form will be process by the State. Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Official Form 030711 2. The Tobacco Product Manufacturer identified above, as of the date of this Certification is: A Participating Manufacturer - OR A Non-Participating Manufacturer in full compliance with Tennessee Tobacco Manufacturers’ Escrow Fund Act of 1999, T. C. A. §§ 47-31-101 et. seq., including having made all required deposits into a Qualified Escrow Fund since the effective date of the Tennessee Tobacco Manufacturers’ Escrow Fund Act of 1999 and any rules and regulations promulgated there under. ALSO COMPLETE OFFICIAL FORM 114780 NPM INFORMATION REQUEST AND SUBMIT IT ALONG WITH THIS FORM. 3. Identify any attorney authorized to represent you regarding your Certification application for listing on the Tennessee Directory. If you do not have an attorney please indicate not applicable. Attorney Name: [ ] Not Applicable Law Firm: Address: City/State/ZIP: Telephone Number: 4. Facsimile Number: Identify any person authorized to provide information to the State of Tennessee or receive information from the State of Tennessee regarding your Certification application for listing on the Tennessee Directory. Name and Title: [ ] Not Applicable Company: Address: City/State/ZIP: Telephone Number: Facsimile Number: Important Note: The State will not process incomplete, unsigned or illegible certifications. Only official State form will be process by the State. Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Official Form 030711 3DUW  ,QGLDQ 7ULEH1DWLRQ $IILOLDWLRQ 5. 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? > @ Yes > @ No B. Is applicant owned by a member(s) of an Indian Tribe/Nation and located on Tribal land? > @ Yes > @ No C. Does applicant have or make any claim of Tribal sovereign immunity? > @ Yes > @ No If your answer to any of these questions is “Yes”, please provide the information requested below and contact the Office of the Attorney General, Tobacco Enforcement Division, P O Box 20207, Nashville, TN 37202-0207, to make arrangements to execute required waivers of sovereign immunity in order to appear on the Directory of Compliant Tobacco Manufacturers in Tennessee. 3DUW  ,QWHUQHW RU 0DLO 2UGHU 6DOHV 6. Does Applicant sell any tobacco products or Cigarettes over the Internet? > @ Yes > @ No 7. Does Applicant sell any tobacco products or Cigarettes by mail order? > @ Yes > @ No 8. Is Applicant in full compliance with Tenn. Code Ann. § 67-4-1029? > @ Yes > @ No 9. If you answered “Yes” to questions #6 or #7, identify all websites the Applicant uses to conduct its Internet or mail order tobacco products or Cigarette sales. 10. If you answered “Yes” to questions #6 or #7, identify all physical addresses where the Applicant conducts its Internet or mail order tobacco products or Cigarette sales operations. 11. If you answer “Yes” to question #6, identify the total Cigarette sales in units sold in Tennessee in the previous calendar year via the Internet. ,PSRUWDQW 1RWH 7KH 6WDWH ZLOO QRW SURFHVV LQFRPSOHWH XQVLJQHG RU LOOHJLEOH FHUWLILFDWLRQV 2QO\ RIILFLDO 6WDWH IRUP ZLOO EH SURFHVV E\ WKH 6WDWH 3DJH  RI  American LegalNet, Inc. www.FormsWorkFlow.com Official Form 030711 12. If you answered “Yes” to question #7, identify the total Cigarette sales in units sold in Tennessee in the previous calendar year via Mail Order. 13. If you answered “Yes” to questions #6 or #7, provide a copy of all Jenkins Act reports filed with the Tennessee Department of Revenue. If you have not filed the required Jenkins Act reports with the Tennessee Department of Revenue, you must prepare and file those reports and provide copies with this Certification before your application will be considered complete. The Jenkins Act report is found at http://state.tn.us/revenue/forms/tobacco/f1309001.pdf. 3DUW  %UDQG )DPLO\ ,GHQWLILFDWLRQ $WWDFKHG DGGLWLRQDO VKHHWV LI QHFHVVDU\ 3DUWLFLSDWLQJ 0DQXIDFWXUHUV FRPSOHWH FROXPQV $ % & 1RQ3DUWLFLSDWLQJ 0DQXIDFWXUHUV FRPSOHWH FROXPQV $) 5HPDLQLQJ RU $GGLWLRQDO %UDQG )DPLOLHV $ %UDQG )DPLO\ % %UDQG 1DPH &,GHQWLI\ &LJDUHWWHV 5