Form Nmago - 2016 - Certification Of Tobacco Product Importer Accepting Joint And Several Liability With Non-Participating Manufacturer For Escrow Compliance In New Mexico And Appointing Resident Agent For Service Of Process Page 3
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3Agent: ____________________________________________________
Company: _________________________________________________
Address: __________________________________________________
Phone: ____________________ Fax:_________________________
Email: __________________________________________________
A current statement from the registered agent certifying service in this capacity must be
attached to the certification.
5. Execution of Certification:
I hereby affirm that all the information stated in this declaration is true and correct, and I
hereby commit the Importer identified above to all the terms of this declaration
________________________________________
(Signature of Declarant)
________________________________________
(Printed Full Name of Declarant)
________________________________________
(Title of Declarant as Officer of Importer)
Notary:
City/County of _______________________, State of _________________________
Subscribed and Affirmed before me on this date: ____________________________
Signature: _________________________ Printed Name: _____________________
Notary Public
My commission expires: _______________________________
Mail this originally, fully executed Certification, including all attachments and supporting
documents to:
New Mexico Attorney General
Attn: Tobacco Project
P. O. Drawer 1508
Santa Fe, NM 87504-1508
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NMAGO – 2016 (2)
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