FORM TT - 19 PM Rev. ( 2 /19 ) Page of Commonwealth of Virginia Note: Responses to all requests below are mandatory. A response must be provided for each request and all indicated supporting documentation must be submitted with the application. Incomplete applications are not eligible for certification review. Type of Certification Application: Certification Year: (Due 30 days prior to any desired change in previously approved Certification Application) Tobacco Product Manufacturer (TPM) Identification: Full Legal Name: Type of Business: Sole Proprietorship General Partnership Limited Partnership Corporation Limited Liability Co. Other (specify) State/Country Where Created, Incorporated, or Registered: Federal Employer Identification Number: Federal Tobacco Manufacturer/Importer Permit Number: Trading as (list all names ever used) : Physical Address: Mailing Address: Phone Number: Fax Number: Email Address: Web Address: Name and Title of Contact Person: Phone Number: Email Address: Name and Title of Person Completing Application: Phone Number: Email Address: If the Tobacco Product Manufacturer is represented by outside counsel for the purpose of compliance with Va. Code 247 3.2-4200 et seq., provide the following: Name: Firm: Address: Phone Number: Fax Number: Email: FORM TT - 19 PM Rev. ( 2 /19 ) Page of Identification of All Fabricators: *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) Identification of All Companies For Whom TPM Fabricates: *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) FORM TT - 19 PM Rev. ( 2 /19 ) Page of Brand Families and Brand Styles the TPM seeks to certify and take Master Settlement Agreement responsibility for: Cigarette or RYO Brand and Style Units Sold in the Previous Calendar Year Previous Fabricator Name Current Fabricator Name *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) FORM TT - 19 PM Rev. ( 2 /19 ) Page of For each Brand Family and Brand Style, list the entity that actually packaged the cigarettes with the US Surgeon General Warnings (cigarettes only): Brand and Style Packager Address Phone *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) FORM TT - 19 PM Rev. ( 2 /19 ) Page of : Required Attachments and Supporting Documentation: (Note: Obtaining and submitting the requested documentation is the responsibility of the Certifying TPM. Any TPM arrangements with regulatory agencies, distributors or other entities necessary to secure such documentation should be made well in advance of the April Certification Deadline.) *cigarettes only 8(i) A copy of the current Centers for Disease Control and Prevention (CDC) Certificate of Compliance and Ingredient Report. *cigarettes only 8(j) For each Brand & Style herein submitted, proof of current Fire Standard Compliance (FSC) approval from the Virginia Fire Marshall's Office, such proof to clearly identify each FSC-approved Brand & Style with descriptions correlating to those submitted for Virginia Tobacco Directory Publication. This proof may consist of either a copy of the relevant Brands & Styles appearing on the (strongly recommended), or of a copy of the Fire Marshall222s final confirmation of registration letter. *cigarettes only 8(k) Is the TPM certified in other states? If yes: provide a list of all other states in which TPM is certified. *(Clearly label each of the exhibits requested above with its associated Request number/letter.) FORM TT - 19 PM Rev. ( 2 /19 ) Page of original Office of the Attorney General Attn: Tobacco Section 202 N. 9th Street Richmond, Virginia 23219 Virginia Department of Taxation Attn: Tobacco Tax Unit P.O. Box 715 Richmond, Virginia 23218 Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer) Under penalty of perjury, I state that (1) the Tobacco Product Manufacturer, as of the date of this Certification, is a Participating Manufacturer in full compliance with the Master Settlement Agreement; (2) the Tobacco Product Manufacturer is in compliance with all applicable sections of Va. Code 2472473.2-4200 through 3.2-4219; (3) I have examined the six pages comprising 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; (4) I understand that the Tobacco Product Manufacturer is required to comply with state and federal laws concerning the sale of tobacco products; (5) I understand that the Attorney General may require additional information and/or documentation to determine if the Tobacco Product Manufacturer qualifies for listing in the Virginia Tobacco Directory; (6) I understand that the Tobacco Product Manufacturer may be Removed from or denied publication on the Virginia Tobacco Directory under the circumstances provided in Va. Code 2472473.2-4206; and (7) I am a qualified company officer authorized to bind the Tobacco Product Manufacturer making this Certification. Name: Title: Phone: Fax: Email: Signature: Date: City/County of , State and Nation of Subscribed and sworn to before me on this date: Signature: My commission expires: