Form Dr 0231 - Tobacco Product Manufacturer Certification (Page 6 of 10) in pdf

Tobacco Product Manufacturer Certification

Supplemental

Initial

Renewal

Part 1—Tobacco Product Manufacturer Identification And Business Information

Company

Street Address

Mailing Address (if different from above)

Telephone

Fax

E-mail

Web site Address

Name/Title of Person Completing Report

Manufacturing Plant(s) Address

Mailing Address (if different from above)

Factory Telephone

Factory Fax

Factory Manager(s)

If Located in the U.S.: Manufacturers Federal Taxpayer ID Number

If Located in the U.S.: Manufacturers TTB Tobacco Manufacturing/Importing Permit Number

If Manufacturer is located in a country other than the U.S., provide copies of any Tobacco Manufacturer’s License/Certificate/Permit or

similar documentation issued by the country where the manufacturing takes place.

The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (Initial one)

________ A Participating Manufacturer under the Tobacco Master Settlement Agreement and has generally performed its financial obligations

under the Master Settlement Agreement.

________ A Tobacco Product Manufacturer in full compliance with § 39-28-201, et seq., C.R.S.

1. Is Applicant the manufacturer (i.e., fabricator) of the brands listed in this Certification that are intended to be sold in the United States,

including cigarettes intended to be sold in the United States through an importer?

Yes No

If your answer is “No,” identify the name and address of the fabricator and state fully the applicant’s basis for seeking to have the brand(s) included in

the Directory. ____________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

2. Is Applicant the first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere that the manufacturer does

not intend to be sold in the United States?

Yes No

If your answer is “Yes,” identify each cigarette manufacturer (i.e., fabricator), its plant street address, mailing address, contact person, telephone

and facsimile phone numbers, and the relationship to applicant. Identify the location of the transfer of ownership of cigarettes and a copy of every

agreement or contract between applicant and fabricator. Attach additional sheet(s), as necessary, to provide a complete response.

_______________________________________________________________________________________________________________________

Note: The state of Colorado will not process incomplete or illegible certifications.

Attach additional sheets as necessary to provide a complete response.