STATE OF NEW MEXICO
Certification of Tobacco Product Importer
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Accepting Joint and Several Liability with
Non-Participating Manufacturer for Escrow Compliance in New Mexico and Appointing
Resident Agent for Service of Process
This Certification must be executed by an officer of the Importer with authority to bind
the Importer to the requirements of New Mexico law as stated below. Execution of this
declaration is an assertion that all information provided below is true and correct, and
that the Importer accepts and agrees to all the terms specified below
1. Tobacco Product Importer Identification:
Company Full Legal Name:_____________________________________________
Type of Business Entity (check one):
□ Sole Proprietorship
□ General Partnership
□ Limited Partnership
□ Corporation
□ Limited Liability Company
□ Other (specify):____________________________________________
State/Country where created, incorporated or registered:_______________
Include the following with this Certification:
A copy of the current Articles of Incorporation, Certificate of Limited
Partnership, Articles of Organization, or comparable applicable document,
including any amendments, must be attached to the certification.
A copy of the Importer’s current Tobacco Importer’s Permit issued by the
United States Alcohol and Tobacco Trade Bureau, with any amendments.
Trading As (list ALL names used)_______________________________________________
Federal Employers Identification Number:_________________________________________
Federal Tobacco Importer Permit Number:_________________________________________
Physical Address:____________________________________________________________
Mailing Address:_____________________________________________________________
Company Phone:_____________________________________________________________
Contact Person:______________________________________________________________
Title:_______________________________________________________________________
Phone:_________________________ Fax:________________________________________
Email:___________________________ Website:____________________________________
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For purposes of this Certification, NMSA, 1978, §7-12-2(H) defines Manufacturer as a person that manufactures,
fabricates, assembles, processes or labels a cigarette or that imports from outside the United States, directly or
indirectly, a finished cigarette for sale or distribution in the United States.
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NMAGO – 2016 (2)