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

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State of Wisconsin
Participating or Non-Participating Manufacturer Certification – Brand Disclosure
C
Schedule
DOMESTIC Little Cigar 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.) for sale in the 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
C -
5. Price per Carton to Distributor for Sale & Distribution in Wisconsin:
( * ) Attach a current price list as Exhibit
Pkg. (i.e. 8/25, 10/20, 10/25, etc.) >>
$
6. Trademark Owner( * ): a. Legal Name >>
b. Doing Business As (DBA) Name
6c. Address:
Street Address
City
State / Province
Country
Zip Code
7. Physical Location(s) where these Little Cigars are fabricated >>
Street Address
City
State / Province
Country
Zip Code
7a. Name of owner of this plant / facility (print or type)
7b. Date First Manufactured
7c. Date Last Manufactured
Reason:
Discontinued
Other
(explain)
7d. Is this the sole facility where this brand / brand style is fabricated?
Yes
No
If No, please explain and complete additional Schedule C for other location(s) and attach.
( * ) Requires attached supporting documents.
CTP-122c (R. 12-04)
Wisconsin Department of Revenue

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