Form Boe-400-Lte - Certification For Manufacturer/importer Tobacco Products License
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1STATE OF CALIFORNIA
BOE-400-LTE REV. 1 (5-12)
BOARD OF EQUALIZATION
CERTIFICATION FOR MANUFACTURER/IMPORTER TOBACCO PRODUCTS LICENSE
Complete this form and mail it to the Board of Equalization, Special Taxes and Fees, P.O. Box 942879, Sacramento,
CA 94279-0088
On behalf of the above manufacturer or importer, the undersigned certifies the following:
1. All of the information contained in the completed Application and Schedule of Tobacco Products Brand Family Names is complete, true,
and correct.
Initial:
Date:
2. If the applicant is a "tobacco product manufacturer" as defined in subdivision (i) of section 104556 of the Health and Safety Code, the
applicant certifies it is one of the following (check appropriate box):
A "participating manufacturer" as defined in subsection II(jj) of the "Master Settlement Agreement" (MSA), or,
Is in full compliance with paragraph (2) of subdivision (a) of section 104557 of the Health and Safety Code.
Initial:
Date:
3. Applicant consents to jurisdiction of the California courts for the purpose of enforcement of the California Cigarette and Tobacco Products
Licensing Act of 2003 and has appointed a registered agent for service of process and identified the registered agent to the BOE and the
California Office of the Attorney General.
Initial:
Date:
4. Applicant certifies that it shall file a monthly report to the BOE, in a manner specified by the BOE, which may include, but is not limited to,
electronic media pursuant to California Business and Professions Code section 22979.21. The monthly report shall include, but is not
limited to, the following:
(1) A list of all distributors licensed pursuant to section 22975 to which the manufacturer or importer shipped its tobacco products or
caused its tobacco products to be shipped.
(2) The total wholesale cost of the products.
Initial:
Date:
5. Applicant understands and acknowledges that under California Business and Professions Code section 22980.1, no manufacturer shall
sell cigarettes or tobacco products to a distributor, wholesaler, importer, or any other person who is not licensed or whose license has
been suspended or revoked. Failure to comply with this section shall be a misdemeanor subject to penalties and fines pursuant to
California Business and Professions Code section 22981.
Initial:
Date:
6. Applicant understands and acknowledges that under California Business and Professions Code section 22979.7, in addition to any other
civil or criminal penalty provided by law, upon finding that a manufacturer or importer has violated any provision of the California Cigarette
and Tobacco Products Licensing Act of 2003, the BOE may take the following actions:
(a) In the case of the first offense, the BOE may revoke or suspend the license or licenses of the manufacturer or importer pursuant to
the procedures applicable to the revocation of a license set forth in section 30148 of the Revenue and Taxation Code.
(b) In the case of a second or any subsequent offense, in addition to the action authorized under subdivision (a), the BOE may impose
a civil penalty in an amount not to exceed the greater of:
(1) Five times the retail value of the seized cigarettes or tobacco products defined as cigarettes under this section, or
(2) Five thousand dollars ($5,000)
Initial:
Date:
CERTIFICATION
I certify that all the information provided in this application is true and accurate and I understand that any person who asserts the truth of any
material matter that he or she knows to be false is guilty of a misdemeanor punishable by imprisonment of up to one year in the county jail, or
a fine of not more than five thousand dollars ($5,000), or both the imprisonment and the fine.
This form must be signed by a corporate officer, LLC member or manager, or an authorized agent, or partner. For a partnership, attach an
authorization signed by all general partners; for a corporation, attach a corporate resolution; for an LLC, attach the articles of incorporation
which authorized the individual who signs below to certify this application. If signed by an authorized agent, a properly completed power of
attorney must be attached to this application.
SIGNATURE
EMAIL ADDRESS
TITLE
NAME (typed or printed)
TELEPHONE NUMBER
DATE
eREG ID#
CLEAR
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