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Form Tt-19-Npm - Tobacco Product Manufacturer Certification For Non-Participating Manufacturers Page 2

FORM TT-19-NPM

If the Tobacco Product Manufacturer is represented by outside counsel for the purpose of compliance

with Va. Code § 3.1-336.1 et seq., provide the following information:

Firm:

Attorney:

Address:

Phone:

Fax:

Email:

Part 3: Registered Agent for Service of Process within the Commonwealth of Virginia

Agent:

Company:

Address:

Phone:

Fax:

Email:

• A current statement from the registered agent certifying service in this capacity must be

attached to the Certification.

Part 4: Fabricator Identification (check one)

□

Tobacco Product Manufacturer is the actual fabricator of the Brand Family(s) it seeks to certify.

□

Tobacco Product Manufacturer causes the Brand Family(s) to be fabricated by another entity.

• If the Tobacco Product Manufacturer is not the actual fabricator, the name and address of the

actual fabricator must be provided and a copy of the manufacturing contract must be attached

to the Certification.

• A list of every Brand Family the Tobacco Product Manufacturer has fabricated, or caused to be

fabricated by another entity, since July 1, 1999 must be attached to the Certification. Indicate with

an asterisk (*) any Brand Family not being sold in the current calendar year, and identify whether

such Brand Family is still being manufactured and by what entity.

Rev. 02.01.05

Page 2 of 6

Form Tt-19-Npm - Tobacco Product Manufacturer Certification For Non-Participating Manufacturers Page 2