Form 611 - Other Tobacco Products (Otp) Manufacturer Report

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OTHER TOBACCO PRODUCTS (OTP)
FORM
611
MANUFACTURER REPORT
Corporate Name
Report Period (Month & Year)
Street Address
OTP License # if located in Maryland
City
State
ZIP code
This report is a complete and accurate record of all OTP delivered to a Maryland licensed OTP wholesaler and OTP tobacconist for the
report month; and all "pipe tobacco" and "premium cigars" delivered to a licensed OTP retailer.
A
B
C
D
E
F
Date
Invoice #
MD Licensee OTP Delivered To
MD License #
Product Type
Invoice
Amount
1
2
3
4
5
6
7
8
9
10
Affidavit
I certify that this report, including schedules, has been examined by me and is to the best of my knowledge and belief a true and
complete report for the month stated.
Print name
Title (Owner, Partner of Officer)
Signature
Date
COM/RAD-ATT-611
Rev. 4/13

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