Form Dr 0231 - Tobacco Product Manufacturer Certification (Page 4 of 10) in pdf

F. 4. PACT Act and Jenkins Act Reporting—The Prevent All Cigarette Trafficking (“PACT”) Act, 15 U.S.C. § § 375,

et seq. requires all persons who sell, transfer, or ship cigarettes or smokeless tobacco in interstate commerce

for profit to: (1) register with the Attorney General of the United States and the Colorado Department of Revenue

(enclose a copy of the registration with this application); and (2) file monthly reports with the Colorado Department

of Revenue, no later than the 10th of each month, identifying the brands, quantities, and recipients of cigarette and

smokeless tobacco shipments into Colorado. These provisions apply to all tobacco product manufactures.

Note: All packages samples, FTC health warning rotations, and CDC compliance letter should be mailed to

the Office of the Attorney General only.

G. Trademark Holders—Identify who holds trademarks on a brand family and provide the address and telephone

number of the holder and the trademark registration number.

H. Affiliates—Identify any Affiliate that also manufactures, imports, distributes, or sells cigarettes or other tobacco

products in Colorado by completing the table on the application. For purposes of this Certification & Application

for Listing, the term “own” means ownership of an equity interest, or the equivalent thereof, of 10 percent (10%) or

more. List the names of the brands and the affiliate in the first two columns. List the type of business by writing in

the third column.

Brand—Identify (1) the brand families sold in Colorado, (2) the distributor/stamping agent used to distribute the

brand family in Colorado, (3) the distributor/stamping agent’s address, and (4) phone number and contacts.

Part 4: Non-Participating Manufacturer Certification

A. V erify that the Non-Participating Manufacturer is registered to do business in Colorado or has appointed an agent for

service of process and provided notice thereof as required by § 39-28-304, C.R.S.

Non-participating Manufactures must either register with the Colorado Secretary of State to do business in Colorado or

retain the services of a registered agent located in the State of Colorado to act as agent for service of process.

If the non-participating manufacturer terminates the agent’s appointment, the manufacturer shall provide notice of the

termination to the Office of the Attorney General and the Colorado Department of Revenue thirty (30) days prior to the

termination and shall provide proof of appointment of a new agent not less than five (5) days prior to the termination.

If the registered agent terminates the appointment, the manufacturer shall provide notice to the Office of the Attorney

General and the Colorado Department of Revenue along with proof of the appointment of a new agent within five (5)

calendar days of the termination.

A current (dated this year) letter from the registered agent accepting this appointment must be attached.

B. I dentify (1) the name, address and telephone number of the financial institution where the Non-Participating

Manufacturer has established a Qualified Escrow Fund pursuant to § 39-28-202(6), C.R.S., and (2) the account number

of such Qualified Escrow Fund and any sub-account number for Colorado. Indicate whether the Attorney General has

approved the escrow agreement, when and by whom.

Part 5: Disclosure of Enforcement Actions (NPM Applicants Only)

Part 6: Applicant Certification (All Applicants)

Signature: The person executing the Certification must do so before an authorized notary.

Note: Any person who makes an assertion in this certification that he or she knows is false regarding

a material matter is guilty of a misdemeanor punishable by imprisonment or a fine, or both.

Form Dr 0231 - Tobacco Product Manufacturer Certification Page 4