Form Dr 0231 - Tobacco Product Manufacturer Certification (Page 9 of 10) in pdf

Form Dr 0231 - Tobacco Product Manufacturer Certification Page 9

Part 4—Non-Participating Manufacturer Certification

A. Registered Agent/Approved Agent for Service of Process

Company

Address

Telephone

Fax

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

B. Qualified Escrow Fund – Financial Institution

Name of Institution

Representative Name

Telephone

Escrow Account Number

State Account Number

Yes No

Has the Escrow Agreement been approved by the Attorney General?

By whom

Approval date

Part 5—Non-Participating Manufacturer Disclosure of Enforcement Actions

1. Enforcement Actions Banning or Enjoining Sales

Has Applicant or any Person or Affiliate of the Applicant had any of its cigarettes banned or enjoined from sale by any

state or federal court or administrative agency within the U.S.? For every such action banning or enjoining sales, list:

a. the Brand Family(ies) banned and/or enjoined

b. the governmental entity (federal, state, local, or foreign) or private plaintiff bringing the action;

c. the case number;

d. the name and address of the government entity or private plaintiff bringing the action.

Yes, the details of each occurrence are attached to this Certification.

Not applicable

2. Denials, Suspensions, Revocations of Permits or Licenses

Has Applicant or any Person or Affiliate of Applicant been denied a permit, license, or been denied any other

authorization to engage in any business relating to the sale of cigarettes by any government entity (federal, state, local,

or foreign) or had such permit, license or other authorization revoked, suspended, or otherwise terminated?

For every such denial, suspension or revocation of a permit, license or other authorization, list:

a. the name of the Applicant or the other Person or Affiliate that had such permit, license, or other authorization

revoked, suspended, or otherwise terminated;

b. the governmental entity (federal, state, local, or foreign) which revoked, suspended, or otherwise terminated the

permit, license, or other authorization;

c. the case number, if any;

d. the name and address of the government entity or private plaintiff bringing the action.

Yes, the details of each occurrence are attached to this Certification.

Not applicable

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 9