Form Tt-19-Pm - Tobacco Product Manufacturer Certification For Participating Manufacturers
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1
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3FORM TT-19-PM
COMMONWEALTH OF VIRGINIA
Tobacco Product Manufacturer Certification for Participating Manufacturers
Part 1: Type of Certification (check one)
□
Initial Certification
□
Annual Certification for Sales Year _______ (Due by April 30 each year)
□
Supplemental Certification (Due thirty (30) days prior to any change in Certification)
Part 2: Tobacco Product Manufacturer Identification
Name:
Federal Employers Identification Number:
Federal Tobacco Manufacturer Permit Number:
Address:
Contact:
Title:
Phone:
Fax:
Email:
Website:
If the Tobacco Product Manufacturer is represented by outside counsel for the purpose of compliance
with the Master Settlement Agreement or Va. Code § 3.1-336.3 et seq., provide the following
information:
Firm:
Attorney:
Address:
Phone:
Fax:
Email:
Rev. 02.01.05
Page 1 of 3
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