Schedule B - Participating Or Non-Participating Manufacturer Certification - Brand Disclosure

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State of Wisconsin
Participating or Non-Participating Manufacturer Certification – Brand Disclosure
B
Schedule
DOMESTIC Roll-Your-Own (RYO / MYO) Cigarette Tobacco Brands
Page
of
Manufacturer Name
Federal Manufacturer Permit No.
WI Dept. of Revenue (WDOR) Manufacturer Permit No.
Certification for Sales Year
TP -
-
TMFR -
BRAND INFORMATION
IMPORTANT ALL brands manufactured and still available for sale to consumers on the U.S. market, on or after May 23, 2000, MUST be listed. Failure to disclose all brands on this application is
cause for delisting and/or denial of all attributed brands.
DOMESTIC BRANDS – Brands manufactured in the United States (U.S.) by the manufacturer above and under the federal permit above.
Mark this box with an “X” to indicate brands you are requesting certification for sale and distribution in Wisconsin for this certification sales year.
X
1. Brand Name
2. Brand Style
3. MSA Status (check one)
4. Brand Reference No.
PM
NPM
B -
5. Cigarette Tobacco Sold as (check one)
6. Price per Package / Bag to Distributor for Sale & Distribution in Wisconsin:
( * ) Attach a current price list as Exhibit
Loose Bulk
Packaged / Brand Labeled
Packaging / Ounces (Oz.) per Bag.
$
Oz.
7. Trademark Owner( * ): a. Legal Name >>
b. Doing Business As (DBA) Name
7c. Address:
Street Address
City
State / Province
Country
Zip Code
8. Physical Location(s) where this cigarette tobacco is blended >>
Street Address
City
State / Province
Country
Zip Code
8a. Name of owner of this plant / facility (print or type)
8b. Is this the sole facility where this process occurs for this brand / brand style?
Yes
No
If No, please explain and complete additional Schedule B for other location(s) and attach.
9. Physical Location(s) where this cigarette tobacco
Street Address
City
State / Province
Country
Zip Code
>>
is packaged for individual sale (i.e. not bulk)
9a. Name of owner of this plant / facility (print or type)
9b. Is this the sole facility where this process occurs for this brand / brand style?
Yes
No
If No, please explain and complete additional Schedule B for other location(s) and attach.
10. Date First Manufactured
11. Date Last Manufactured
Reason:
Discontinued
Other
(explain)
( * ) Requires attached supporting documents.
CTP-122b (R. 12-04)
Wisconsin Department of Revenue

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