Form Dr 0231 - Tobacco Product Manufacturer Certification (Page 3 of 4) in pdf

Form Dr 0231 - Tobacco Product Manufacturer Certification Page 3

State of Colorado

TOBACCO PRODUCT MANUFACTURER CERTIFICATION

PART 1. TOBACCO PRODUCT MANUFACTURER IDENTIFICATION

Company

Address

Phone

FAX

Name/Title of Person Completing Report

The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (Initial One)

_______ A Participating Manufacturer under the Tobacco Master Settlement Agreement

_______ A Tobacco Product Manufacturer in full compliance with C.R.S. 39-28-201, et. seq.

PART 2. SALES YEAR

Year of Sales for this Certificate of Compliance is __________ (Complete a separate certification for each year of sales)

PART 3. BRAND FAMILY IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY)

Participating Manufacturers complete A & B; Non Participating Manufacturers complete A, B, C & D.

A. BRAND FAMILY

B. BRAND NAME

C. UNITS SOLD

D. MANUFACTURER

Indicate with an asterisk (*) those brands that will not be sold in 2005. The brands indicated with an asterisk (*) will be removed from

the Colorado Certified Brands Directory the month following the receipt of the Certificate of Compliance for the 2004 year of sales.

Form Dr 0231 - Tobacco Product Manufacturer Certification Page 3