Form Das 116 - Application For Fire-Safe Certification Of Cigarette Manufacturer printable pdf download

Form Das 116 - Application For Fire-Safe Certification Of Cigarette Manufacturer

DAS 116 (10-08)

APPLICATION FOR FIRE-SAFE

CERTIFICATION OF

BUREAU OF BUSINESS TRUST FUND TAXES

CIGARETTE MANUFACTURER

PO BOX 280909

HARRISBURG, PA 17128-0909

BRANDS ADDENDUM

DATE:

PART 1. MANUFACTURER IDENTIFICATION

Company Name:

Brands Addendum Page

PART 3. BRAND FAMILY CERTIFICATION – FIRE SAFE CIGARETTES ATTACH ADDENDUM PAGES AS NECESSARY

The manufacturer certifies, under penalty of perjury, that it is a cigarette manufacturer in full compliance with the Cigarette Fire

Safety and Firefighter Protection Act. The cigarettes included in this certification have been tested in accordance with the American

Society of Testing and Materials Standard E2187-04 “Standard Test Method for Measuring the Ignition Strength of Cigarettes.” For

each cigarette sought to be certified as compliant with Pennsylvania Cigarette Fire Safety and Firefighter Protection Act list the

brand, such as the trade name on the package; test date(s); style, such as light, ultra light; length in millimeters; circumference

in millimeters; flavor, such as menthol, chocolate, if applicable; filter or non-filter and package description, such as soft pack, box.

Brand

Test

Style

Length and

Flavor

Filter/

Package

(trade name

Date(s)

(light,

Circumference

(menthol,

Non-Filter

(soft pack,

on package)

ultra-light)

(in millimeters) chocolate, etc.)

box, etc.)

The Department will not process incomplete or illegible certifications.

Form Das 116 - Application For Fire-Safe Certification Of Cigarette Manufacturer