Rob McKenna ATTORNEY GENERAL OF WASHINGTON Website: http://atg.wa.gov/Tobacco/SuppliersandManufacturers.aspx STATEMENT OF REGISTERED AGENT Please print or type in permanent dark ink Sign, date, and return original to: ATTORNEY GENERAL’S OFFICE REVENUE DIVISION PO BOX 40123 OLYMPIA, WA 98504-0123 TOBACCO PRODUCT MANUFACTURER: ________________________________________________________________________ hereby appoints _____________________________________________________________________________________ as its registered agent to accept service of process on our behalf. Signature ____________________________________________________________ Date _____________________ Print Name ___________________________________________________________ Title _________________________________________________________________ NAME AND ADDRESS OF WASHINGTON STATE REGISTERED AGENT: Name _________________________________________________________________________________________ Street Address (Required – Must be Washington State) _____________________________________________________ PO Box (Optional – Must be in same city as street address) __________________________________________________ City _______________________________________________________________, WA Zip ___________________ Telephone _________________________________________ I consent to serve as Registered Agent in the State of Washington for the above named Tobacco Product Manufacturer, pursuant to Laws of 2003, ch. 25. I understand it will be my responsibility to accept Service of Process on behalf of the Tobacco Product Manufacturer; to forward mail to the Tobacco Product Manufacturer; and to immediately notify the Office of the Attorney General if I resign or change the office address of the Registered Agent. Signature ____________________________________________________________ Date _____________________ Print Name ___________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com