Official TN Form 114780 March 4, 2011 Page 1 of 4 State of Tennessee NPM Information Request Pursuant to Tenn. Code Ann. §§ 67-4-2601 et seq. Please type or legibly print in permanent blue ink. Use additional pages as necessary. (This Form may be filled out on-line, however, all signatures must be executed in permanent blue ink.) Applicant name: Street Address: City/State/Zip/Country: Mailing Address (if different from above): City/State/Zip/Country: Telephone number: Facsimile number: E-mail address: The following documents must be attached to your 2011 Certification Form for Listing on Tennessee’s Directory. Initial by each number to confirm that each document requested is attached and labeled appropriately: 1. Samples - Samples (or legible, identical size, color copies of all sides of the packaging thereof) of the current packaging and labeling used for each of the individual brands within each Brand Family listed in Part 3 of the 2011 Certification Form for Listing on Tennessee’s Directory. Initial to confirm that you have attached these documents. 2. Permits & Licenses to Manufacture Cigarettes - A copy of all permits, licenses or other authorization to manufacture tobacco products issued by any governmental entity, whether located in the United States or elsewhere. This includes importer’s certificate, trademark holder’s certificate, etc. Initial to confirm that you have attached the requested documents. 3. Certificate of Compliance (cigarettes only) - A copy of the current Centers for Disease Control (CDC) ingredient-listing compliance letter(s) pertaining to the brands listed in this certification and a statement from the manufacturer as to which brands’ ingredients were submitted for each approval letter. Initial to confirm that you have attached the requested documents. 4. FTC Warning Rotation Information (cigarettes only) - A copy of the complete current health warning rotation plan submitted to the Federal Trade Commission (“FTC”) pursuant to 15 U.S.C. § 1333 and a copy of the approval letter from the FTC for each brand family applicant wants listed. If the Certification Applicant sells or intends to sell Cigarettes that are not made in the United States, please identify the name and address of the entity that submitted the ingredient reporting information to the U.S. Secretary of Health and Human Services. Initial to confirm that you have attached these documents. 5. Brand List - Provide a complete list of all tobacco product Brand Families, (including all cigarettes, rollyour-own, cigars, little cigars, pipe tobacco, smokeless tobacco, etc.) currently and previously manufactured by the (Non-Participating) Manufacturer, its principals, subsidiaries, affiliates, successors, members, officers, owners and directors. This list is in addition to the list provided for certification. List whether or not sold in the U.S., the dates during which each Brand Family is, or was, manufactured, and place of manufacture for those brands. Initial to confirm that you have attached these documents. 6. Trademark Information - A list of the trademark owners, including street address and telephone number for each Brand Family identified in the Certification for Listing on Tennessee’s Directory. Initial to confirm that these documents are attached. American LegalNet, Inc. www.FormsWorkFlow.com Official TN Form 114780 March 4, 2011 Page 2 of 4 7. 8. Trademark Holder’s Certificate - A copy of the trademark holder’s certificate under penalty of perjury that it has not withdrawn consent to import into the United States as required by 19 U.S.C. 1681a(c)(3)(A) or a copy of the importer’s certificate under penalty of perjury that the trademark owner has not withdrawn consent to import into the United States as required by 19 U.S.C. 1681a(c)(3)(B). Initial to confirm attachment that these documents are attached. Photographs – a) Provide four clear color photographs taken within 90 days of this application of at least four inches by six inches of the exterior of each side of each of your manufacturing facilities. Each of the photographs must provide clear and unobstructed views of each side of the outside of the manufacturing facility(ies). Each photograph must be labeled on the back with the name of the factory, the full street address of the factory, the date of the photograph was taken and the full name, address and telephone number of the person who took the photograph. Initial to confirm that these documents are attached.. b) Provide five clear color photographs taken within 90 days of this application of at least four inches by six inches of the interior of each manufacturing facility. The photographs must provide at a minimum the following: (a) clear and unobstructed views of the majority of the interior of the manufacturing facility, (b) clear and unobstructed views of the number of manufacturing lines and machines in operation in the manufacturing facility, (c) clear and unobstructed views of the manufacturing facility in operation, and (d) clear and unobstructed views of the number of employees normally working in the manufacturing facility when it is in operation. Each photograph must be labeled on the back with the name of the factory, the full street address of the factory, the date of the photograph was taken and the full name, address and telephone number of the person who took the photograph. Initial to confirm that these documents are attachedt. 9. Notice of Appointment of Registered Agent – Attach official form number 86971. Form is located online at www.attorneygeneral.state.tn.us/cpro/pdf/gent.pdf. Please also submit a current letter (dated this year) from the registered agent accepting this appointment. Initial to confirm that the form and acceptance letter are attached to this form. 10. Stamping Agent and/or Distributor – For each stamping agent or distributor of your products possessing a Tennessee wholesale license, please provide the name, address, telephone, facsimile numbers and all brand families delivered to each stamping agent or distributor. Initial to confirm that this information is attached. 11. Delivery Service Information Reports – If Applicant advertises or sells Cigarettes via the Internet or in catalogs and uses the mail or other delivery service to deliver Cigarettes to Tennessee Consumers. Please provide a copy of all Delivery Service Information Reports (RV-F1309001) filed with the Tennessee Department of Revenue during calendar year 2010. This form is located online at: www.tennessee.gov/revenue/forms/tobacco/f1309001.pdf. Initial to confirm that these reports are attached or list “N/A” if no such sales have taken place. 12. Contract Agreements - A copy of all contract agreements for any brand of Cigarettes that the Company intends to sell directly or indirectly in Tennessee through an exclusive wholesaler and/or distributor. Initial to confirm that such agreements are attached or list “N/A” if there are no such agreements. 13. Company Officers and Owners – Provide a complete list of all officers and company owners (all persons with an equity interest of 10% or more in Applicant Company.) Include names, address, phone and facsimile numbers, date and place of birth and email address for each person identified and include whether any of the individuals identified have ever been involved with the manufacturing, importation or distribution of tobacco products manufactured by entities other than your Company? If so, plese identify the Brand Families and entities with which the individuals have been involved and explain the level of involvement, including the dates of any and all involvement. Initial to confirm that this information is attached. 14. Contract Manufacturing Agreements - A copy of all contract manufacturing agreements for any brand of Cigarettes that the Company intends to sell directly or indirectly in Tennessee. This applies only if the applicant intends to sell any cigarettes that are manufactured by entities other than the applicant. Initial to confirm that such agreements are attached or list “N/A” if there are no such agreements. American LegalNet, Inc. www.FormsWorkFlow.com Official TN Form 114780 March 4, 2011 Page 3 of 4 15. Judgments and Governmental Action – Provide a complete list of all judgments against the Company in any U.S. state or federal court or other administrative proceeding (excluding worker’s compensation); all pending lawsuits against the Company in any U.S. State or federal court, including the name of the action, the court where filed, the case number and the current status; and all past and present actions by any government (located either in the U.S. or elsewhere) that resulted in a suspension or revocation of a license or permit held by the Company, or that sought a suspension or revocation of any license or permit held by your Company. Initial to confirm these documents are attached or list “N/A” if none exist. 16. Invoices - Copies of the invoices for any cigarettes and roll-your-own manufactured by your Company sold in the United States during the previous calendar year. You may provide documents in electronic format. You may also provide customer detail in Excel format in lieu of invoices if it includes the following information: date, invoice number, customer name and account number, brand, quantity and price, subtotals and totals. Initial to confirm that these documents are attached or list containing proper information from invoices. 17. Organizational Documents required to be provided with Certification application: IF APPLICANT IS A: Partnership or Association Corporation ATTACH TO CERTIFICATION FOR THE FOLLOWING: Current copy of articles, if any, or the certificate required to be filed by any state, country or municipality along with verification that the document(s) was filed with the appropriate governmental agency. A copy of the Company’s corporate charter or certificate of corporate existence or incorporation along with verification that the document(s) was filed with the appropriate governmental agency. This copy must be executed by the appropriate state officer for the jurisdiction of incorporation. AND Limited Liability Company Extracts from stockholders’ meetings, bylaws, directors’ meetings or other documents that list the officers authorized to sign documents or otherwise act on behalf of the corporation. The accuracy of the extracts provided by the Company must be certified by an appropriate officer of the corporation. Current copy of the business document(s) filed with a state, county or municipality if such filing is required along with verification that the document(s) was filed with the appropriate governmental agency. AND Other business organization An accurate copy of its operating agreement. Current copy of the business document(s) filed with a state, county or municipality of such filing is required along with verification that the document(s) was filed with the appropriate governmental agency. _____ 18. Escrow Agre ement. Attach a copy of the company’s current escrow agreement including any amendments that have been executed thereto. Initial to confirm that a current copy of this agreement is attached. _____ 19. NPM Bond. Attach official form number 092809 if you are a “newly qualified” NPM. Please see Tenn. Code Ann. § 67-4-2602 to determine whether your company meets this definition. A sample form of such a bond is located online at http://www.tn.gov/attorneygeneral/tob/pdf/npmbond.pdf along with a copy of the bond required by Tennessee Code Annotated section 67-4-2602 in the amount of $100,000. Initial to confirm that the bond information is attached or list “N/A” if not necessary. Please note the State has the right to request additional inform ation. You will receive a letter(s) requesting additional information if the State so elects. Your application will not be complete until all information requested in any letters from the State is also provided. American LegalNet, Inc. www.FormsWorkFlow.com Official TN Form 114780 March 4, 2011 Page 4 of 4 Manufacturer Certification Under penalty of perjury, I state that, to the best of my knowledge, all of the information contained in this Certification and any attached documents are true and accurate. This document must be signed and dated by an authorized notary public. _________________________________________________ _________________________________ NPM Authorized Designee (Print Name) Title _________________________________________________ _________________________________ Signature of NPM Authorized Designee Date Subscribed and sworn to before me on this date__________________, in the County of _________________, in the State of ______________________. ______________________________________ _________________________________ Signature of Notary Public Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com