FORM TT-19 NPM Rev. (2/19) Page 1 of 11 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. Request 1: Type of Certification Application:Certification Year: (Due 30 days prior to any desired change in previously approved Certification Application) Request 2: 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 Emp loyer Identification Number: Federal Tobacco M anufacturer /Importer Permit Number : Trading as (list all names ever used) : Physical Address: Mailing Addres s: 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: Request 3: Name(s), Phone Number(s), Email(s), Title(s), Address(es) and Dates of Service for all Current and Past Officers, Directors and or Partners. Name: Phone Number: Email: Title: Address: Dates of Service: Name: Phone Number: Email: Title: Address: Dates of Service: *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) Certification Application for Non-Participating Tobacco Product Manufacturers (NPM) American LegalNet, Inc. FORM TT-19 NPM Rev. (2/19) Page of 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: (if applicable) Registered Agent Identification for Service of Process within the Commonwealth of Virginia for NPM located within the United States: Company: Agent: Address: Phone Number: Fax Number: Email: (if applicable) Registered Agent Identification for Service of Process within the Commonwealth of Virginia for NPM and/or importers located outside the United States: Company: Agent: Address: Phone Number: Fax Number: Email: Identification of All Fabricators: *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) American LegalNet, Inc. FORM TT-19 NPM Rev. (2/19) Page of Identification of All Companies For Whom TPM Fabricates: *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) List every Brand Family the Tobacco Product Manufacturer has manufactured, or caused to be fabricated by another entity, since July 1, 1999: STYLE & BRAND Sold in Current Year? Y/N Still Being Manufactured? Y/N TPM Name / Other Fabricator Name *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) American LegalNet, Inc. FORM TT-19 NPM Rev. (2/19) Page of Brand Families and Brand Styles the TPM seeks to certify and take Escrow Statute (Va. Code 247 3.2-4200, et seq.) 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.) American LegalNet, Inc. FORM TT-19 NPM 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 Name Address Phone *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) For each Brand Family, list the stamping agent(s) to whom the TPM222s cigarettes and/or RYO tobacco products are sold and/or that affixes the Virginia excise tax stamps to cigarettes and/or pays excise tax on RYO tobacco products: Brand Family Company Name Address Phone Number *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) American LegalNet, Inc. FORM TT-19 NPM Rev. (2/19) Page of Internet and Mail Order Sales: *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) Qualified Escrow Fund: Financial Institution: Agent: Physical Address: Mailing Address: Phone Number: Fax Number: Email Address: Account Number: Commonwealth of Virginia (Sub)Account : American LegalNet, Inc. FORM TT-19 NPM Rev. (2/19) Page of ItemizedEscrow History for the Commonwealth of Virginia (Sub) Account: Date Deposit Withdrawal Balance *(Attach additional pages if needed. Clearly label the exhibit with its associated Request number.) Disclosure of Enforcement Actions, Prior Determinations and Assertions: 16(a) 000