Official TN Form 86971 10/28/2005 NON-PARTICIPATING MANUFACTURER’S NOTICE OF APPOINTMENT OF REGISTERED AGENT FOR STATE OF TENNESSEE AND REGISTERED AGENT'S STATEMENT Please type or legibly print in permanent blue ink. (Please note this form may be filled out on-line. However, any signatures must be in permanent blue ink) Sign, date, and return original to address indicated in Definitions and Instructions. SECTION 1. Under the provisions of Tenn. Code Ann.§ 67-4-2603, any non-resident or foreign Non-Participating Manufacturer (“NPM”) that has not registered to do business in Tennessee shall, as a condition precedent to having its brand families included or retained in the Directory of compliant Tobacco Product Manufacturers, engage the uninterrupted services of an agent for service of process in Tennessee. This agent must be authorized to receive service of process on whom all process, and any action or proceeding concerning or arising out of the enforcement of Tenn. Code Ann. §§ 67-4-2601, et seq. and Tenn. Code Ann. §§ 47-31-101, et seq. may be served in any manner authorized by law. Such service shall constitute legal and valid service of process on the NPM. The undersigned NPM, hereby appoints as a registered agent. Said registered agent is authorized to receive service of process on behalf of the NPM. The NPM agrees to do the following: (1) provide notice to the Office of the Attorney General for the State of Tennessee ("Attorney General"), at least 30 calendar days prior to termination of the authority of the registered agent; (2) provide proof to the satisfaction of the Attorney General of the appointment of a new agent at least five (5) calendar days prior to the termination of an existing agent appointment. The undersigned NPM further agrees that if the agent terminates its agency appointment, the undersigned shall provide notice to the Attorney General of the termination within five (5) calendar days and shall include proof to the Attorney General of the appointment of a new agent. The registered agent must be appointed in the name of the Non-Participating Manufacturer, not in the name of an importer, distributor or any other entity. Under penalty of perjury or falsification, I, certify and declare that all of the statements and information contained in this Certification, including but not limited to, any accompanying statements or attachments herewith, are true, correct, accurate and complete in every respect and that I am a person authorized to bind the NPM making this document either under the laws of the State of Tennessee or of the jurisdiction where the manufacturer resides or is organized and I have attached an authentic, certified copy of document(s) as proof of my authority to bind the NPM. Any violation of the requirements of Tenn. Code Ann. §§ 47-31101 et seq. or Tenn. Code Ann. §§ 67-4-2601, et seq. or any rules and regulations promulgated thereunder is a basis for removal of the undersigned NPM and its Brand Families from the State’s Directory. ** This Form must be signed and dated by an authorized notary public.** Signature of Authorized representative for the NPM Manufacturer: Authorized representative of NPM (Print Name): Title: Principle Place of Business (physical address): City/State/Zip Code: Telephone number: STATE OF COUNTY OF E-mail address: Facsimile number: ) ) On before me, , 200 , 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. Signature Printed Full Name of Notary: My Commission Expires: QImportant Note: The State will not process incomplete, unsigned or illegible forms or affidavits. Only Official State forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com Official TN Form 86971 10/28/2005 Page 2 of 2 SECTION 2. NAME AND ADDRESS OF TENNESSEE REGISTERED AGENT: Name: Street Address (Required - Must be within Tennessee): City /State/Zip Code: Post Office Box (Optional - Must be in same city, state as street address): City /State/Zip Code: Telephone Number: Facsimile Number: E-mail Address: I, consent to serve as Registered Agent in the State of Tennessee for the above named Non-Participating Manufacturer (“NPM”), pursuant to Tenn. Code Ann. § 67-4-2603. I understand it will be my responsibility to receive, sign and date Service of Process on behalf of the NPM; to forward mail to the NPM; and to immediately notify the Office of the Tennessee Attorney General at the above address if I resign or change the office address of the Registered Agent. ** This Form must be signed and dated by an authorized notary public.** Under penalty of perjury and falsification: Signature: Date: Print Name: Title: STATE OF COUNTY OF ) ) On ,200 , before me, , 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. Signature of Notary: Printed Full Name of Notary: My Commission Expires: QImportant Note: The State will not process incomplete, unsigned or illegible forms or affidavits. Only Official State forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com