Form Dr 0231 - Tobacco Product Manufacturer Certification (Page 7 of 10) in pdf

Form Dr 0231 - Tobacco Product Manufacturer Certification Page 7

3. I s Applicant a successor of an entity described in the last two questions (i.e., manufacturer or first importer)?

Yes No

4. I f Applicant checked “no” on the last three questions above, explain the basis for applicant’s claim that it is a Tobacco

Product Manufacturer as defined under section 39-28-202(9), C.R.S., and submit all documentation to support

applicant’s contention. Attach additional sheet(s), as necessary, to provide a complete response.

_______________________________________________________________________________________________

Part 2—Certification Year

The year for which certification of these brands is being requested is ________ (A separate certification is required each year)

Part 3—Brand Family Identification

(To be completed by all TPMs. Attach Additional Sheets, if necessary)

Indicate with an asterisk (*) those brands that will not be sold in 2013. The brands indicated with an asterisk (*) will be removed from the Colorado

Certified Brands Directory the month following the acceptance of the Certification of Compliance

E. Date Certified

A. Brand Family

B. Brand Style

C. Cigarette or RYO

D. Units Sold

F. Manufacturer

Fire-Safe

F. Manufacturing Information:

1. Provide a Sample of the packaging for each brand family, preferably on CD.

Initial Application: Samples of the actual packaging and labeling for each brand are attached.

Supplemental Application: Samples of the actual packaging and labeling for each supplemental brand are

attached.

Renewal Application: Samples of packaging for all brands and products sought to be certified in the current

year have been previously provided and there have been no changes in the packaging.

Renewal Application: Changes in packaging of previously submitted samples have occurred and new

packaging samples are attached.

2. F or each of the above brand families (cigarettes only) provide a copy of the current Federal Trade Commission (FTC)

approval letter for health-warning rotation plan. Additional information can be obtained at:

Federal Trade Commission

600 Pennsylvania Avenue, N.W.

Washington, D.C. 20580

General Information Telephone: 202-326-2222

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

Attach additional sheets as necessary to provide a complete response.

Form Dr 0231 - Tobacco Product Manufacturer Certification Page 7